Laparoscopic treatment for apical defect with promontofixation

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Laparoscopic treatment for apical defect with promontofixation

Authors

Keywords

prolapsus cystocèle,hystérocèle coelioscopie

Media type

Surgical video

Duration

24'00''

Publication

2005-12

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E-publication

WeBSurg.com, Dec 2005;5(12).
URL: http://www.websurg.com/doi-vd01en1764.htm

Laparoscopic treatment for apical defect with promontofixation

1. Trocar placement 00'13''

I will just put the trocar in. We can inflate the patient. You see that in this patient particularly if you want to go into the anterior Retzius’ space, you will have no problem even though she is fat, you can see the landmarks nicely. The fat tissues are mostly on the abdominal wall between the skin and the fascia and also on the omentum around the bowels. The trocars I use are very simple and cheap ones.

2. Exposure 00'59''

Here we have now the system which is a little bit anteverted so we have to straighten it. This is the pure apical defect, there is no cystocele.

3. Vesicovaginal dissection 01'34''

We must first dissect the bladder flap, I take the bladder and push up and you see nicely the limit. My assistant will take the bladder so I know that here I just have the peritoneum. The first camera we were using was a numeric one and we now have the three-chip camera, a new model from Karl Storz. I do like to have a grasping bipolar for these operations. It is definitely a big improvement in surgery, the concept of using both energies at the same time a long time ago but I still stick to this and I even think that it is the future of laparoscopic surgery. I don’t believe in energies like ultrasound for laparoscopy, and on the contrary using both energies at the same time really works for everything. I have reached the right plane, so I am just going to dissect a little bit because there is no evident cystocele, so I just want to get the space to attach my mesh at the front. I am going to free this space up to the bladder pillar here that I just cut a little bit in order to pass close to the vessels and move above them to reach this peritoneal area. The bladder pillar is very strong in this patient so it’s a sign that the cystocele is not that big. I do some freeing just for passage. I then go down to try and identify the vessels, you must stay away from them. Here we start to see a vein, must free away from these veins too. You must be very careful in obese patients because here you have a grey area and you must know that under it there is a vein. I will show that to you by passing around the vein. We start to see the relief of the vein. This is the vein here and this is the peritoneum there. The cervix is here and the vagina starts here. We can see very nicely the difference between the cervical area and vaginal area. Here is the manipulator I can feel that it is hard here, then this is the vagina and you pull and where you stop is the limit of the cervix!!!

4. Windows preparation 05'29''

She has no pregnancy desire and her husband is sterile but she wants to keep the uterus. I prepare my window here, this is where I want the branch of my mesh to go, not too low because I am going to attach the mesh here to the torus uterinus so I am going to dissect a little bit. Here is the grey area we have seen so we are going to open it here. You should not be going too far out, the ureter is here. Do a small window and then start dissecting towards the insertion of the uterosacral ligament in order to get more tissue to cover the mesh at the end, because the problem when you do a conservation of the uterus is to peritonise. In techniques done by laparotomy we peritonise with the sigmoid. So I just cut a little bit, this is the insertion of the uterosacral and here we can probably dissect a little more to prepare the passage of the strip. The strip will come here and pass through that. Let’s go to the promontorium to see if we can view it easily.

5. Sacral promontory preparation 06'56''

It is not so bad, you see some fatty tissue on the root, the promontorium is here. It is better if we attach it. We do the same on the other side instead of taking the meso which is much more fragile. Once again the assistant pushes the sigmoid. We have to catch the peritoneum here to coagulate and to incise. We must proceed slowly, especially in obese patients. The direction of pushing up is very important so I can see my way. Like this so you can go closer to the edge, you see the gas shows you the way. I am under the uterosacral ligament close to the pelvic side wall and I don’t need to go too low as this part here does not need to be dissected. I am not going to go on the rectal part, this is just for peritonisation. I’m going to stop here. If the ovaries disturb you, you can attach them. This is the insertion of the uterosacral, they are very weak as you can see and this is normal. She has a deep pouch of Douglas, which does not mean that she has a rectocele. You can see that the rectum goes up back, so we are close to the levator ani muscles. Now we must go back to the promontorium, pull the peritoneum back, I am going to open a little bit more towards the bifurcation, towards the left iliac vein; we must now be quite careful, we are going to the presacral space. We are not going to go inside because there is no need, but you know that even in these obese patients you can still dissect it. Obviously we have some vessels here, it should be the pre-sacral vessels. We are a little too lateral so we will find our way gently. We begin to see the ligament and I will try to find a plane. If you can’t, you grasp this and then open it. You have seen the ureter. Step by step we can now see the sacral vessels and we begin to see the pre-vertebral ligament under the fat. I feel the ligament is softer here than there; here it is too laterally so it’s too dangerous for the nerves so we attach it here. We now check the opening we have on the uterus. We prepare the peritoneal window by gently going down and find our passage zone. You see the small window, it’s enough so let’s go to the other side. You can ligate both uterine arteries and most of the time you still get a uterus that is still alive, you even get some pregnancies. Before I put the mesh I want to finish something on the back because it is going to help for the peritonisation. I am going to go lower and get more tissue, I open just a little bit the other side in order to get more free tissue. I don’t have to go too much to the back, just a little here and check where the rectum is, it is better not to injure the bowel. I will use a little bit of the rectum to peritonise. Here we don’t need to do it because I will not attach the bowel I will just take the peritoneum to cover. Now I am going to use a polyester mesh.

6. Anterior mesh placement 13'42''

This is a mesh with a width of 5cm that I opened in two parts at the front and made an opening for the uterus and this is going to be attached to the promontorium. I place the mesh, go to my window, pull it up here. I now change my needle holder, it could be a flat forceps. Now we can lift it up. Now we need Ethibond. At the level of the cervix, the tacker could have been used, because you are not going to the vagina but to the cervix. I will use the knot pusher. We don’t have to tie the bladder, remember that the dissection was short, the goal was not to treat a real cystocele. First of all, you need to know where you are going to tie the vagina. Here it is important not to pull too much on the vagina. You take the two sutures to be sure that you hold the vagina and we will put one on each side. The advantage of this is that you really reconstruct the pericervical ring which is a problem in these types of prolapse. If the patient wishes for pregnancy, you can take two steps; the first is to do the same and she will obviously deliver by caesarean section, or you don’t pass on the uterine side, but you stay on the back part of the pelvis and I have done a lot of patients like this, many young patients with big defects of the pelvic support and they are treated by anterocystoplasty and covering of the abdominal wall. They then developed when they were around 18-20 years old, a huge apical default. In those patients I just re-attached the mesh to the torus uterinus and it was sufficient. This is enough for the anterior mesh, it’s always better to trim the useless tissues. The posterior part of the mesh is here. We will now attach this part here when we are going to pull on it, you see we pull on all the parts of the vagina.

7. Anterior peritonization 17'09''

I will show you one simple technique for performing in and back continued suture. You see that we just do a rotation, I take my distance even though with this type of suture we don’t need to do it, and we go back. Now I go out and it should not normally block. If the suture is not a monofilament, if it’s a Vicryl, it is very important to take your distance at the end of the first row.

8. Posterior mesh fixation 18'19''

Here we need to know where the uterosacral ligament is, and here it is. See the epigastric vessels, I will pass here; the best way to do that is get your needle back, turn it immediately to the other side in order to avoid the epigastric. This is a very easy technique you can use for any type of work you do on the cul-de-sac such as severe endometriosis, etc. We do the peritonization.

9. Posterior peritonization 19'24''

You usually have to do it in two points, one left, one right, I will start with the left side. Very important to do it before pulling. I am now going out and will ask to have the uterus pulled a little bit down to give me more freedom during the freeing of the tissue; when I am going to tie, I will not break everything. I will now close the posterior point; to do so, we need to take the rectum. Having prepared the small incision posteriorly, you have a lot more possibilities to start with the peritonisation. We are going to do the promontofixation, we need a zero Ethibond. The problem is that it is quite hard to get a needle holder which is good enough for holding and presenting tissue. Here you must pay attention to the ureter. I am not going to tie now because if I tie I will pull on the peritoneum and if I do so, I will hide the sacral promontorium. I leave my suture without tension so I can still pull on my peritoneum here. If I tie, I will pull like this and the access to the promontorium will not be easy.

10. Promontofixation 22'24''

I will try to avoid sacrificing the medial sacral artery, I stay on the left side of the artery and am going to check if this is solid enough. Pull on the mesh. Place the fundus of the vagina in this area, here there is no culdoplasty, so we have to tie. I am going to pass twice, tie and then check. Now I close this one. It is better to remove the excess mesh. In terms of results, it gives you a very soft posterior and anterior support, you don’t even feel the mesh. I am not saying that we get better results than those with polypropylene soft meshes, but for me they are easier to work with so I have benefits rather than inconveniences. Even though this patient is quite obese, we found a way and slowly, step by step we fixed the problem. I like to work with this type of mesh (Parietex®) because it is soft, has no memory, is easy to pass through and this patient will be able to leave hospital the next day.