Laparoscopic promontofixation with uterine preservation

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Laparoscopic promontofixation with uterine preservation

Authors

Keywords

promontofixation,rectocystocèle

Media type

Surgical video

Duration

12'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1668.htm

Laparoscopic promontofixation with uterine preservation

1. Exposure and anatomy 00'10''

This video will demonstrate laparoscopic promontofixation with uterine preservation. Exposure and the identification of anatomical landmarks is a fundamental step of the procedure. Important landmarks include the sacral promontory, suspensory ligament of the ovary, external iliac vessels, the 2 layers of the broad ligament, the vesicouterine fold and the superior portion of the bladder. On the left side, it is essential to control the attachments of the sigmoid colon, which can be freed to facilitate exposure.

2. Sacral promontory preparation and rectovaginal dissection 00'42''

The first step of the procedure is the preparation of the sacral promontory. When the promontory is visible through the peritoneum as in this case, massive coagulation is initially performed. The peritoneum is then incised. The incision is continued towards the rectouterine pouch of Douglas taking care not to damage vascular structures. The dissection is continued down to the posterior part of the uterosacral ligament on the right side. It is appropriate to start the rectovaginal dissection at this level. Now the assistant retracts the rectovaginal peritoneum caudally to help the surgeon incise the peritoneum. The peritoneum may be strongly attached in the midline particularly if the dissection here is too high. The pneumoperitoneum facilitates the dissection on either side by opening up the tissue planes. We can now identify the rectum medially, the middle rectal vessels laterally and the levator ani muscles inferiorly. On the right side, the puborectal and pubococcygeal muscles can now be recognized. Now the dissection is continued on the left side, which tends to be ergonomically more difficult for the surgeon. A combination of blunt and sharp dissection is used to reach the level of the levator ani. Medially the dissection should continue down to the anorectal junction to allow for the placement of the prosthetic mesh on the lower side of the rectum. We can now clearly identify the dissected rectum and the pelvic floor. The dissection should be performed to create enough space for the 26mm needle, which will be used for prosthesis fixation.

3. Vesicovaginal dissection 03'19''

Now to the dissection of the vesicovaginal plane. The bladder is retracted cephalad by the assistant and the peritoneum is opened from one round ligament to the other. The dissection is continued inferiorly until the vesicovaginal plane is identified. It is important to progress inferiorly on the midline as lateral dissection risks urethral injury. The dissection is continued until the upper limit of the trigone of the bladder is reached. The balloon placed in the bladder facilitates the identification of the limit of dissection. Laterally a window is created posterior to the uterine vessels for the placement of the prosthetic strip. The dissection is continued until the grey colour of the retrovascular area is seen on both sides. This would be the point of fixation of the mesh.

4. Mesh fixation 04'34''

Following the dissection, the prosthetic strip is prepared. This is a triangular shape with a posterior slip to enable the passage of the limbs laterally. The first step is the posterior fixation onto the levator ani muscles. A strong non-absorbable suture on a 26mm needle is used to fix the mesh on to the puborectal line on the right side. Bleeding during needle introduction should be controlled by the knots. If not, coagulation can be used. Now to the left side: care must be taken to keep the needle away from the rectum. A good bite is necessary for secure prosthesis fixation. No medial fixation to the vagina is necessary as the lateral sutures keep the mesh in position, and the vaginal suture may cause vaginal erosion. Following the fenestration procedure, the end of the mesh strip is brought back anteriorly underneath the bladder first on the left side, and then on the right. Exposure is important during this step. The uterus should be lowered and then retracted cephalad in order to avoid any vascular injury. Now an anterior Ethibond stitch is placed to the lowermost part of the previously dissected vesicovaginal plane. This approximates the 2 lower extremities of the mesh together. As a result, the mesh strip is positioned low and in contact with the bladder. Additional stitches help reconstruct the vesicovaginal fascia underneath the bladder. Now the peritoneum and bladder can be repositioned back into its original position.

5. Anterior peritonization 06'57''

Anterior peritonization is performed by approximating the peritoneal edge and the former pillar of the bladder. This suture helps the cephalad traction of the bladder, which helps avoid recurrence of cystoceles underneath the prosthesis. Vicryl is used for the peritonization.

6. Posterior culdoplasty 07'35''

Once the anterior peritonization is complete, a posterior McCall culdoplasty is performed in order to restore a normal vaginal access posteriorly. Ethibond is used to suture the prosthesis, root of the uterosacral ligament, the rectovaginal ligament and the cardinal ligaments successfully on both sides. Here we can see the origin of the uterosacral ligament and the rectovaginal ligament on the left. The sutures on either side are tied at this point.

7. Posterior peritonization 08'28''

It is essential to perform posterior peritonization before the promontofixation is carried out. The objective is to exclude the mesh and reposition the rectouterine pouch by performing a Douglasectomy using a 0 polypropylene suture. A purse-string stitch is placed on the left side through the peritoneum of the uterosacral ligament and rectum.

8. Promontofixation 09'06''

The peritoneal incision is also approximated on the right side. Promontofixation is achieved using a 1 polypropylene suture onto the anterior longitudinal ligament of the vertebra. The mesh is then assessed and adjusted to gain the correct tension. The tension on the prosthesis should be low. It is the posterior culdoplasty stitch, which controls the position of the vaginal flow and the mesh is really only there for safety.

9. Final peritonization 09'47''

A final peritonization is now achieved. A double running suture of Vicryl or Monocryl is used without too much traction on the peritoneum. At the end of the procedure, peritoneal lavage is performed and hemostasis is achieved.

10. Transobturator suburethral tape 10'26''

In this particular case, the patient presented with associated urinary incontinence and so a transvaginal tape prosthesis is also placed. The incision is made 1cm below the urethral meatus and the dissection is performed towards the pubic branches. Two skin incisions are then made in the genitofemoral groove at the level of the clitoris. A Hemet needle is passed first through the adductal ligaments, then in the obturator membrane, and finally across the right side. The polypropylene tape is then placed on both sides. The sling should be in a sub-urethral position with no tension. An instrument can be placed between the urethra and the sling to ensure this and to avoid dysuria. Once the adjustment is made, the sling is cut. The vagina is then sutured using a continuous polypropylene stitch. Now a check is performed externally to ensure the reduction of any rectocele or cystocele. The skin incisions are then closed. No vaginal drain is necessary if there is no bleeding.