Laparoscopic treatment for genitourinary prolapse

Nowadays, there is a consensus upon treating genitourinary prolapse with mesh placement. Anterior and posterior mesh placement can be done by a transvaginal or an abdominal approach. Such a laparoscopic approach should be considered as a gold standard in terms of anatomical and functional long-term results. We present a case of laparoscopic prolapse treatment with double anterior and posterior sacral mesh fixation.

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Laparoscopic treatment for genitourinary prolapse

Authors

E Mandron, C Saussine, J Marescaux

Abstract

Nowadays, there is a consensus upon treating genitourinary prolapse with mesh placement. Anterior and posterior mesh placement can be done by a transvaginal or an abdominal approach. Such a laparoscopic approach should be considered as a gold standard in terms of anatomical and functional long-term results. We present a case of laparoscopic prolapse treatment with double anterior and posterior sacral mesh fixation.

Classification

routine cases

Keywords

Laparoscopic treatment, genitourinary prolapse

Media type

Surgical video

Duration

20'26''

Publication

2009-03

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Subtitles

E-publication

WeBSurg.com, Mar 2009;9(03).
URL: http://www.websurg.com/doi-vd01en2551.htm

Laparoscopic treatment for genitourinary prolapse

1. Introduction 00'06''

Nowadays, there is a consensus upon treating genitourinary prolapse with mesh placement. Anterior and posterior mesh placement can be done by a transvaginal or an abdominal approach. Such a laparoscopic approach should be considered as a gold standard in terms of anatomical and functional long-term results. We present a case of laparoscopic prolapse treatment with double anterior and posterior sacral mesh fixation.

2. Case description 00'32''

This woman is 50 years old and she has had a symptomatic stage 3 cystocele without any incontinence and with constipation. The urodynamic exploration is normal. Professor Saussine offers to perform a laparoscopic repair of the prolapse.

3. Patient positioning 00'46''

The position of the patient is very important. The 2 arms of the patient are alongside the body because when you work for this kind of surgery, we work at shoulder level. The patient is in a modified lithotomy position as well as a Trendelenburg (with a 30 degree tilt) from the very beginning in order for the bowel to move upwards. It is important also to have an easy access to the vagina because during the dissection, you’ll need to help yourself with the blade in the vagina. It is important also to cover the blade with a glove to prevent injury of the vagina. We will place it in the vagina to help in mobilization and exposure of the anterior and posterior wall. Then to have a clear access to the vagina, the buttock will be placed 3cm out of the table, which will help for these maneuvers.

4. Insufflation and port placement 01'36''

After insufflation with a Veress needle, we will place 4 ports, a 10mm one for the optic, and then three 5mm ports. The first 5mm one will be placed in the midline between the suprapubic bones and the umbilicus. The second one will be about 2cm inside to the superior iliac crest, and the 3rd one will be placed symmetrically. The three 5mm ports are on the same line. While the nurse was draping the patient, we were preparing the mesh, the posterior part is 6cm wide and 15cm long with a previous first stitch for the pelvic muscle. The anterior mesh is 4cm wide, same length with also a stitch on it.

5. Exposure 02'43''

The first step is the exposure. With a straight needle, I transfix the abdominal wall and the uterus just at the level of the suprapubic bone, so just with this fixation, the posterior exposure will be done very easily. And we will do the same with the sigmoid. So just with these two exposures, now you can have a real good surgical exposure and the bowel will no longer be seen during the whole laparoscopic procedure.

6. Peritoneal incision and posterior dissection 03'23''

The first step is to see the sacral ligament. So we incise the peritoneum. Here it can be risky because you can have the crossroad with the iliac vein. Slowly you will find the ligament. At the end, there is no problem since you can fix it. The second step is to reach the uterosacral ligament on the right side. It’s essential to do a large and deep dissection because you will have to do the peritonization at the end of the surgery. Now you can see clearly the uterosacral ligament and you have to pass underneath it. Just incise here. When this is done, we have to open the Douglas’ pouch. You can do an omega incision from the left uterosacral ligament to the right one. Now the nurse will move the blade, which is in the vagina. I will load the posterior wall of the vagina. This is an essential operative step. We can complete the freeing laterally. Now you can see the rectum so you have to stay close to the vagina at this level. You can see the blade. We have to mobilize the posterior wall of the vagina to find the good plane between the rectum and the vagina. Now the posterior aspect of the vagina is clearly visible. Now we are going to reach the levator ani muscles. We reach the end of the posterior dissection here. We are at the level of the posterior fork of the vagina. Here the dissection begins to be difficult. Then you just have to go laterally and look for the muscle. I am immediately at muscle level. I’ll do exactly the same on the right side. And now clearly I am on the muscle. At the end of the dissection, you have this classical view like a face (the nose could be the rectum and the 2 eyes the 2 little holes for the fixation of the posterior mesh).

7. Fixation of the posterior mesh 06'10''

Because we have only one 10mm port, we will pass the mesh through this port. So the mesh is inside and now we begin the fixation. I use polypropylene mesh (Prolene) because this material is well tolerated by patients nowadays. It’s important to avoid any ulceration of the vagina. The first time is again to expose the posterior wall of the vagina and to place your stitch and then go in this little hole. It’s essential to take the muscle only and not the rectum. Here clearly with my other grasper, there’s a protection from the rectum. So the first stitch is placed. We will place a second one. And now I’ll take the part of the posterior mesh. I used to work with 2 needle holders. The posterior part of the mesh is fixed now. It’s important for us to avoid any fixation on the vagina because you can have ulceration later on. And now I will fix the upper part of the large portion mesh to the uterosacral ligament. For exposure purposes, the nurse moves the blade and you can take just here. Be careful at this level because here you have the vagina and the vaginal cul-de-sac. More cephalad, I will be through the vagina and you can have ulceration several years afterwards. Here we take the large portion of mesh and we fix it. This fixation is essential because the traction on the mesh will be done through this ligament and through the pelvic fixation. The last stitch is for the other side. The right ureter is just here as you may see it. Be careful here. That’s why I like to have a large dissection on this side. If I did a large stitch, it could be dangerous. So I have to take only the uterosacral ligament to have a fixation and we know that the mesh will stick to the other organs and it will be sufficient to have a good fixation. You can see really nicely the dissection and the fixation, the rectum is free and all the posterior wall. You see that I will close immediately.

8. Beginning of the posterior peritonization 09'44''

I will close the Douglas’ pouch beginning by taking the peritoneum at the level of the left uterosacral ligament, then the Douglas’ pouch, the peritoneum at the level of the right uterosacral ligament and return to the first point, this purse-string suture close the Douglas’ pouch. I leave the needle here and I will gather it at the end of the surgery. I will now create a window through the ligaments here. At the end, the peritoneum will come here to close this window.

9. Creation of the ligament’s windows 11'07''

Before releasing the uterus, I will create the two windows through the ligaments. That is the peritoneum from the upper part. I stay in contact with this peritoneum in order to go to the prevesical space. At this point, you must have an avascular dissection because here there could be a vessel coming from the cervix and you must be very careful. We will do the same on the other side.

10. Anterior inter-vesico-vaginal dissection 11'49''

We now release the uterus and you will immediately see the 2 pouches laterally. Here and here we have done the dissection, we just have to do the incision now between the two. The mesh will cross the uterus from both sides. Now you just have to do the dissection between the vagina and the bladder. At this moment, I think it is important to avoid placing the blade, because if you do so, then you push the bladder and you’ll have an injury of the bladder. I will place the blade in the anterior wall, see the blade, the bladder is not so far. I will just finish the dissection. At this level, we can reach the ureter here. We must be careful at this level because we arrive at the end of the dissection and you can imagine seeing the ureter here at this level. It is important to have an ample dissection, because we will fix the mesh somewhere here, but if you haven’t done a large dissection, you can fix it to the ureter here.

11. Fixation of the anterior mesh 13'22''

The first stitch is medial, and you see that I will have to avoid being transvaginal. I will try to be as superficial as possible. I will place five stitches, now the other one on the other side, you can see here clearly where I will have to put it. These 2 last stitches are very important because you have to fix the upper part of the mesh to the isthmus of the uterus to avoid a secondary hysterocele. I will take a large part of my mesh just here. The nurse will open this space. I will take the vagina and the upper part laterally to the cervix. The anterior fixation is ended. The 2 tails of the anterior mesh are now passed through the windows on each side.

12. Sacral fixation 16'17''

We see now the end of the fixation and we just have to do the sacral fixation and the surgery will be complete. We will place the mesh. This is the only extracorporeal knot. See I introduce the thread like this. This fixation is a little bit difficult because you are just at the same level between your ports, tools and ligaments, so you have to be careful with the vein. This is a good stitch and now we will fix it on the three meshes. The first mesh we fix is the posterior mesh and we will fix it without any traction, you just have to drop it like this. For the anterior one, you will place a bit of traction just to make sure that the cystocele is cured. At this moment, I will do an intracorporeal knot to block it. We just need to cut the lengths of the mesh that are in excess.

13. End of the posterior peritonization 18'28''

We will take the previous Vicryl to finish the peritonization. I take the peritoneum and here, the other windows, left first, then the isthmus and here the right window, and at the end the free peritoneum that we have freed. These stitches will completely close the posterior mesh, you can see here clearly the peritoneum, which is going up. I just have to take this, it will be closed and all the mesh will be under the peritoneum. Now you can no longer see the mesh, we just have to finish the suture of the peritoneum without any tension; it is very important at this moment to have no tension. I just have to close the peritoneum. We will detach the sigmoid to free the tension on it, it helps for the end of the peritonization.

14. Anterior peritonization and end of procedure 19'52''

You see that during this procedure we have never seen the bowel. I finish with the closure of the vesicovaginal space with a running absorbable suture. We will not place a drain and this is the end of the procedure. We look at the orifice of the ports to see if there is no bleeding, exsufflate the patient and close the incisions. The catheter will be taken out on postoperative day one and the patient can leave at day two.