Laparoscopic sacral colpopexy: correction of cystocele and rectocele with two meshes

Mesh placement appears nowadays to be consensual upon treating genitourinary prolapse by the vaginal or abdominal approach. Laparoscopic sacral fixation with two meshes should be considered as a gold standard in terms of anatomical and functional long-term results. We present a case of cystocele and rectocele grade 2 treated laparoscopically with anterior and posterior sacral mesh fixation.

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Virtual University

LAPAROSCOPIC   SACRAL   COLPOPEXY:   CORRECTION   OF   CYSTOCELE   AND   RECTOCELE   WITH   TWO   MESHES

Authors
Abstract
Mesh placement appears nowadays to be consensual upon treating genitourinary prolapse by the vaginal or abdominal approach. Laparoscopic sacral fixation with two meshes should be considered as a gold standard in terms of anatomical and functional long-term results. We present a case of cystocele and rectocele grade 2 treated laparoscopically with anterior and posterior sacral mesh fixation.
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Duration
26'31''
Publication
2011-12
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en
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en
E-publication
WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3567.htm

LAPAROSCOPIC   SACRAL   COLPOPEXY:   CORRECTION   OF   CYSTOCELE   AND   RECTOCELE   WITH   TWO   MESHES

4. Exposure and identification of sacral ligament 04'16''
So now we will fix the uterus with a straight needle, just at the level of the pubic bones and I will transfix the uterus just for the exposure. And we will just place a little grasper just to fix the uterus. You see now how it’s done, and again I will do the same on the left side for the bowel, for the sigmoid loop. I take the fat loop and I will fix it just like this. You are able to work without moving the bowel, so just exactly the same, you go to the outside. Everything is prepared, and it was just due to the Trendelenburg position at the first time of the installation, and fixation of the sigmoid loop for us and the uterus. So now the first landmark is to find the sacral ligament. You let the gas go inside, you see here, clearly, and the first thing you have to find is really the contact of the ligament, and here, one danger can be the left iliac vein, it can cross here so you have to be very careful. I will enlarge my incision a bit, just to be sure, before carrying on, I want to be sure, to be really in contact with the sacral ligament. It is the beginning of the surgery, so you have to take your time at this point, because at the end you have to go back there to place a stitch, so if it’s well prepared, you don’t have to go on this side again. Take your time. When you see the typical white aspect of the ligament, you are sure you’re doing it right. I will have to enlarge my incision a little bit. I think now clearly you see very well the sacral ligament, and now we can go on.
5. Peritoneal incision and inter-rectovaginal dissection 06'47''
The second landmark will be to reach the right uterosacral ligament, and here you see the typical aspect of the arch, due to the traction of my assistant, who is doing the exposure and then you just have to follow this, you see, and to inside on this arch. And then you enlarge slowly and you follow this trying to find this plane, typical aspect of this plane, and you don’t create a plane, and you mustn’t be in the fatty tissue, because you’re not in the right place, you should just be in between the mesorectum and the peritoneum here. And you just go on and follow it. It’s a totally avascular plane. When you arrive at the level of the sacral ligament, uterosacral ligament on the right side, you have to pass under it. You can see laterally the ureter, which is here. It goes here, so if you go inside the uterosacral ligament, you can’t have an injury of the ureter, so here you have to do the bifurcation and go inside. And you go until you reach the Douglas’s pouch. And you go on slowly, releasing the attachments. It’s important at this time to go deep and to do a large incision. You see now. So now, we start the second step, is to open the Douglas’s pouch and to reach the uterosacral ligament on the left side. I have done a large incision, and now you have to find the plane. Sometimes it’s difficult because on the medial side you can have adhesions, so you have to do a traction, and slowly go on and find a plane. Normally it’s an avascular plane, you can see it now, and the rectum is just behind. At this time, I don’t place the blade. I start the dissection without the blade in the vagina, to avoid pushing the blade, to push the vagina or the rectum in contact with the scissors. You see here it’s a little bit sticky but we go on slowly, and slowly we will find the plane. And now, I’m sure I’m in the right plane, so I’m able to place the blade, just right now, but not before. The blade is in the vagina, you see here in the Douglas’s pouch, and now you can clearly see the right place here. It’s totally avascular. I have to stay in contact with the vagina, as high as possible to be as far as possible from the rectum. You always have to replace, you catch the vagina and slowly you open. The exposure is very important, because the blade must be parallel to the scissors. When it’s totally released, it is easy. At this time, you stay medially, you don’t go laterally because you have all the vessels coming from the uterus, and you go on until you reach the level of the anus. I just stay medially and I just follow the plane and when you go on, you will slowly reach a difficult zone to dissect because you are at the end of the dissection.
9. Anterior inter-vesicovaginal dissection 17'38''
So now when it’s done, we release the uterine fixation. When you have done the dissection well, normally you can find here the 2 holes with the gas because of the previous dissection so now I’ll just have to incise the peritoneum at this level and to immediately find the 2 holes previously done. You see now I’ll find the first hole immediately, and the second one on the other side. So the legs of the anterior mesh will pass at this level. And now I have to find the plane in between the isthmus of the uterus and the vagina. So at this time, I don’t place the blade at the beginning. Then I will have to follow this plane; you’ll quite always find a good plane laterally and when it’s done, when you’re sure that you are in the good plane, then you can go and release medially because you know that it’s nothing and you see you’ll find the good plane quite immediately now. And what is important is to find an avascular plane again; if it’s bleeding, you’re not in the good plane. You are in contact, you are in the detrusor, in the muscle. See now slowly we go on and we reach now the good plane. Now I’ll give the bladder to my assistant, and my other assistant will place the blade not posteriorly, but in the anterior cul-de-sac. And you see clearly that we’re exactly at the good level; here there are still some little attachments from the bladder. See always I’m in contact with the blade, I know exactly where I am. At this level, you can find the ureter so you have to be careful.