Grade 4 cystocele and hysterocele repair by laparoscopic promontofixation with uterine preservation

A 71-year-old woman presented with a cystocele grade 4, a hysterocele grade 4 and a rectocele grade 2 during physical examination. As the patient did not want to perform a hysterectomy, she underwent a laparoscopic promontofixation with uterine preservation.

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Grade 4 cystocele and hysterocele repair by laparoscopic promontofixation with uterine preservation

Authors

A Wattiez, P Trompoukis, J Nassif, S Maia, A Vázquez Rodriguez

Abstract

A 71-year-old woman presented with a cystocele grade 4, a hysterocele grade 4 and a rectocele grade 2 during physical examination. As the patient did not want to perform a hysterectomy, she underwent a laparoscopic promontofixation with uterine preservation.

Keywords

Grade 4 cystocele repair, hysterocele repair, laparoscopic promontofixation, uterine preservation, prolapse

Media type

Surgical video

Duration

22'13''

Publication

2011-01

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E-publication

WeBSurg.com, Jan 2011;11(01).
URL: http://www.websurg.com/doi-vd01en3149.htm

Grade 4 cystocele and hysterocele repair by laparoscopic promontofixation with uterine preservation

1. Exposure 00'31''

Before starting the procedure, the exposure and the anatomical landmarks must be done. The suspension of the bowel will help you identify the sacral promontory easily. In this particular case, the exposure is even more important due to the obesity of the patient.

2. Sacral promontory dissection and incision of the right lateral peritoneum 01'40''

We start the procedure by opening the peritoneum at the level of the sacral promontory towards the right uterosacral ligament. At the level of the promontorium, we must identify the large vessels that cross the promontory and the ureter that passes close to the dissection. The dissection at the level of the uterosacral ligament, which is usually difficult, is very important to free the ureter. The mesh can then be covered without stretching the ureter.

3. Rectovaginal disection 03'01''

The rectum is stretched towards the sacrum by the assistant to put the peritoneum under tension and make the dissection easier. The dissection continues as far as possible until the rectovaginal junction. At this point, the surgeon must identify the levator ani muscles (puborectalis, pubococcygeus, and iliococcygeus).

4. Bladder dissection 05'58''

In this surgery, bladder dissection is performed lower than normal to facilitate the placement of the mesh. To ease the dissection, the assistant must hold all the bladder, not only the bladder peritoneum.

5. Preparation of the promontorium 08'09''

The objective of this part of the intervention is to dissect this space broadly enough to place the needle correctly.

6. Posterior mesh fixation 09'12''

The mesh is fixed posteriorly on both lateral sides at the level of the puborrectalis muscle using extracorporeal knots with a non-absorbable polyfilament suture.

7. Anterior mesh fixation 11'23''

The mesh is fixed normally with a single stitch at the paravaginal tissue in order not to transfix the vagina and by using a extracorporeal knot with a non-absorbable suture, as we have done in the posterior fixation of the mesh.

8. Connection of posterior with anterior mesh 13'49''

It is done to fix only one arm of the mesh in the promontorium and to avoid leaving too much foreign tissue in the body of the patient. When we pass the needle through the promontorium, we only include the fibrous layer of the aponeurosis to reduce the risk of spondylodiscitis.

9. Low peritonization 16'33''

The peritoneum is closed above the mesh using an absorbable monofilament suture. This is an important step of the surgery because most complications occur due to lack of peritonization.

10. Fixation of the mesh in the promontorium 19'28''

The mesh must be fixed in position. We turn around the mesh with the suture to enhance the fixation in the promontorium.

11. Final peritonization 20'17''

During the peritonization, it is important not to take the mesh because if we take it, the suture will be blocked.

12. End of surgery 22'05''

The anatomical result of the surgery is demonstrated.