You need to log in to watch this media!

Click here to log in.

Laparoscopic promontory fixation for prolapse of the vaginal vault and enterocele with placement of transobturator tape sling (TOT)

Authors

A Wattiez

Media type

Duration

12'00''

Publication

2005-05

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1754e.htm

Laparoscopic promontory fixation for prolapse of the vaginal vault and enterocele with placement of transobturator tape sling (TOT)

1. Trocar placement and exploration of cavity 00'06''

This video demonstrates the laparoscopic treatment of uterine prolapse combined with a posterior enterocele. At the beginning of the procedure, we use three 5mm trocars. Trocars are placed laterally external to the rectus abdominis muscles and contralateral to the anterior superior iliac spines. A mid-line trocar is positioned in the same access. Exploration of the cavity reveals no abnormalities in the patient’s anatomy. The following structures can be seen: the lumbo-ovarian ligament, the external iliac vessels, the bladder anteriorly with its peritoneal fold, and finally the round ligament to the left. The procedure starts with the retraction of the small bowel. The anterior vertebral ligament is cauterized. Opening of the peritoneum then follows.

2. Opening of peritoneal reflection 01'10''

Carbon dioxide diffuses into the retroperitoneal space to facilitate dissection. The incision is initiated laterally from the sacral promontory towards the rectouterine pouch. Incision ends at the level of the uterosacral ligament. The rectum is then grasped and pulled down by the assistant. The peritoneal incision is continued to allow complete diffusion of CO2 and facilitate access to the rectovaginal space. The vagina must quickly be identified. It represents an anatomical boundary to be followed until the levator ani muscles laterally are seen. Several vessels are found at this time of dissection in the fatty tissue. They should be carefully coagulated to maintain a good anatomic view. The rectum is identified here. A cleavage plane must be found laterally as the footage shows. Once the plane is found, the levator ani muscles are visible. Laterally there are 3 muscles: the puborectalis muscle in contact with the viscera, the pubococcygeal muscle posteriorly, and the ilio-coccygeal muscle. It is essential to complete the dissection towards the anorectal junction medially and the puborectalis muscle laterally. It will facilitate the lateral fixation of the mesh and correction of the rectocele medially. Cautery is performed progressively. The posterior wall of the vagina is clearly identified and followed until the anorectal junction is reached. Care must be taken to achieve complete hemostasis throughout the dissection. Hemostasis helps to prevent any postoperative bleeding between the mesh and the vagina. The hematoma resulting from a postoperative hemorrhage may become infected and become a complication. In this case where the uterus is preserved, dissection is performed underneath the bladder, which is retracted cephalad by the assistant. The vesicovaginal plane is identified. The dissection is started there to be continued towards the region situated above the trigone of the bladder.

3. Rectovaginal dissection 03'30''

Dissection should be discontinued here since fixation of the mesh to the trigone may induce instability and cause pain for the patient. The bladder pillars are either divided as it is the case here or preserved. Dissection is carried out more laterally to identify the translucent areas of the peritoneum. At this level, the peritoneum is opened to allow introduction of the mesh. Attention must be paid not to injure the vessels, which are often very deep in the fatty tissue, and thus may go unnoticed. A greyish area is seen here. It may be opened. The vessels are identified and dissection may be started slightly underneath them proximal to the uterosacral ligament, which marks the limit of the deperitonealized area. Dissection underneath the uterosacral ligament may be performed once the ureter has been identified and kept at a distance. The same procedure is performed on the right side. The greyish area is visible. A window opening is created. It may be done above the uterosacral ligament since it is easier to achieve on the right side. The peritoneal incision is enlarged if necessary to obtain a better operative view. In case of doubt, the dissection must be performed deep within to identify the ureter, which may be obscured by the mesh. Here the uterine and obturator vessels are identified. The ureter lies underneath. In this case, the posterior dissection can be difficult but it is easy to identify the plane of the levator ani muscles on the right side. Dissection is pursued until the anorectal junction is reached medially. Dissection on the left side is always more difficult as it is carried out from the surgeon’s side. Anatomically speaking, the rectum tends to be to the left. It is essential to start dissection laterally to find a correct dissection plane heading towards the levator ani muscles. Here you can see the end of the dissection. The mesh can be introduced.

4. Mesh tailoring 06'16''

The mesh used is made of polyester. It is cut to a 30cm length and 5cm width. The anterior end is slit. It is timed to accommodate the isthmus of the uterus. The mesh is introduced into the abdominal cavity. A 5mm medial trocar is replaced by 12mm trocar to facilitate suturing.

5. Mesh placement 06'40''

The operative steps are the following: the posterior portion of the mesh is fixed to the levator ani muscles. In case of bleeding as happens here, care must be taken to suture ligature and achieve hemostasis. Otherwise, bipolar cautery can be used. Large sutures are utilized in attaching the mesh to the muscles caudally. The anterior tails of the mesh are placed bilaterally to bring the 2 anterior mid-portions above the bladder. Here on the right side, we face a difficulty in accessing the window opening. For this problem is rapidly solved. The mesh is brought back medially and anchored using Ethibond suture material. It is fixed as caudally as possible above the trigone, thereby re-approximating the 2 ends of the mesh at the lowermost portion of dissection. A median stitch is made to attach the mesh cephalad. Lateral stitches help to stretch out and anchor the mesh. All sutures must be performed superficially as they are anchor points and no tension will be applied.

6. Mesh fixation 08'00''

There should be no transfixing sutures to prevent erosion. The mesh is fixed posteriorly, then anteriorly. The anterior reperitonealization is carried out by threading the bladder pillars. The bladder exerts traction on the mesh. The risk of a subprostatic cystocele is avoided with this technique. The second right lateral stitch is made to achieve complete reperitonealization anteriorly. We use a 2/0 Vicryl suture to approximate the peritoneum. The uterus is anteverted. The 2 ends of the mesh are joined together at the insertion of the uterosacral ligaments. During this step, the root of the uterosacral ligament and the rectovaginal ligament are threaded. The stitch made here is essential for several reasons: the rectum is tented on the mesh, the closure of the space is completed, the correction of the enterocele is achieved, and the risk of recurrence should be reduced to none with this technique. Two stitches are preferred instead of using a purse-string technique to avoid injuring the rectum, which can then lead to postoperative constipation. Then the mesh is attached to the promontory with a stitch. To do so, it is necessary to start applying the first stitches for the caudal reperitonealization. These may be difficult to achieve and afterwards once the mesh has been attached to the promontory. Reperitonealization is carried out using either Vicryl 2/0 or Monocryl 2/0, which is handy to use but is not ideal for secure knot-tying. This stitch for promontory fixation is done superficially to the vertebral ligament using Ethibond 0 or 1 suture diameter. One single stitch is sufficient here. The mesh is positioned without tension. A second stitch may be applied for stability reasons. Reperitonealization will be completed laterally using a running suture with Monocryl or interrupted sutures with Vicryl. Reperitonealization must be complete to avoid any intestinal adhesions with the mesh, which may then lead to small bowel occlusion or fistula formation. Here the footage shows the end of promontory fixation. Examination shows the reduction of the rectocele and the preservation of the vaginal length. A transobturator suburethral tape or TOT is then placed in this patient as she is presenting with urinary incontinence resulting from sphincter insufficiency.

7. TOT 11'11''

The incision is performed one and a half centimetres from the vaginal meatus. Dissection is then carried out laterally with scissors to favor the introduction and placement of a fingertip underneath the iliopubic branches to the right and to the left. Under finger control just after the incision, approximately at the level of the clitoris and the inguinal fold, a needle is pushed through the adductor’s longest attachment and the obturator muscle and membrane. The needle is then withdrawn through the vaginal incision. The TOT sling is passed in the head of the needle and slid through the vaginal incision to the left and to the right. The tape is then positioned under the urethra without tension. It is cut at the end of the procedure in cases of significant pelvic variceal bleeding, a vaginal drain can be used. The vagina is closed with a running 2/0 Vicryl suture. The skin is closed with an inverted Monocryl suture. This patient did well postoperatively and this completes our procedure.

Username
Password
	Remember me (needs cookies)