Laparoscopic treatment of genitourinary prolapse

The treatment of vaginal prolapse is described. The rectovaginal and rectovesical space are dissected; the mesh is placed into rectovaginal space. The tunnel in the broad ligament on the right just above the uterine artery is created and the anterior vesicovaginal mesh is placed into this tunnel. Both anterior and posterior meshes are fixed to the promontorium and the pouch of Douglas is closed. The peritoneum is closed over the mesh.

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Laparoscopic treatment of genitourinary prolapse

Authors

Abstract

The treatment of vaginal prolapse is described. The rectovaginal and rectovesical space are dissected; the mesh is placed into rectovaginal space. The tunnel in the broad ligament on the right just above the uterine artery is created and the anterior vesicovaginal mesh is placed into this tunnel. Both anterior and posterior meshes are fixed to the promontorium and the pouch of Douglas is closed. The peritoneum is closed over the mesh.

Classification

controversial cases

Keywords

urology,operation,gynecology,prolapse

Media type

Surgical video

Duration

14'00''

Publication

2002-08

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E-publication

WeBSurg.com, Aug 2002;2(08).
URL: http://www.websurg.com/doi-vd01en1335e.htm

Laparoscopic treatment of genitourinary prolapse

1. Case presentation 00'11''

Our case today is a 53-year-old woman who has a grade 2 to 3 cystocele. She has pain but no stress and urinary incontinence. She has a grade 1 rectocele and a grade 1 hysterocele. Four trocars are used: one in the umbilical position, one in the midline suprapubic position, one in the right iliac fossa and one in the left iliac fossa.

2. Exposure 00'36''

You can see here the fibrotic portion of the sacral promontory, which will be the seat of fixation for the mesh. You can see the ureter here, the iliac pedicle, the ureter again, the uterus is here; this will be fixed; this provides traction; this is the posterior vaginal wall, the uterosacral ligament on the right and left side.

3. Dissection of rectovaginal plane 01'16''

You begin your incision of the peritoneum in the midline, which thereby avoids the rectum. You incise and the force of the pneumoperitoneum aids in the separation of the tissue planes. You can then enlarge the access. With posterior progression of the dissection, you can see the rectum and the inferior part of the surgical field; moving upward, the vaginal wall is located in the midline and liberated from the surrounding tissues. Once should exercise great care here to avoid damage to the rectum. This is the anterior part of the rectum; we then progress on each side of the rectum to access the muscular plane of the levator ani muscles. Again, we need to enlarge our access a bit. In the midline, we still have some fibres between the posterior vaginal wall and the rectum. Now you can see the posterior vaginal dissection, access to the right side of the muscular plane, and it’s enough space to pass a needle to fix the mesh in this part, access to the left side of the muscular plane: it should be enough here; it can be quite difficult on the side because it’s very deep.

4. Posterior mesh placement 03'13''

The mesh and its needle are then placed through the optical trocar in the umbilicus. We place the needle with good muscular bite and we have to make sure that the needle tip exits far from the edge of the rectum. You can see the importance of the assistant here. You use the curve of the needle and place tension on the stitch. It’s quite deep in this case but I can reorient. Now I’ve got a good muscular bite and it’s away from the rectum. This is the left leg of the mesh. I lock the knot and push the tip towards the middle; it’s the most technically difficult part. Now I’m going to fix the mesh flush against the posterior vaginal wall and avoid any wrinkling.

5. Closure of rectouterine pouch 05'09''

This schematic shows where the needle and thread are passed to close the rectouterine pouch. We avoid passing the needle through the vagina because we have had problems with necrosis and infection of the mesh. We fix the mesh in the paravaginal tissue and the uterosacral ligaments. The next step is to close the space of Douglas and we use this larger opening. Now I go on the right side and get passage through the peritoneum without rectal injury you can see it here. Again I follow the curve of the needle so that I can come out exactly where I want. And you can see the space is closed now.

6. Promontory preparation 06'31''

We have good exposure of the sacral ligament and you can see that in this case it’s very clear. You can ask your assistant to retract the peritoneal plane and you incise deep to the peritoneum just by the midline. You enlarge the access once you have created it. Be careful of the bowel. Once you have incised the peritoneum, you begin to create the space for passage of the prosthesis on the right side of the pelvic cavity. Now you’ve created a channel for the mesh, which will be placed at the end of the procedure. The vertebral ligaments are here. This will be in contact with the mesh and we’ll pass the needle later. Now we can go to the anterior side of the prolapse. We will prepare a channel for the mesh here.

7. Dissection of vesicovaginal plane 07'49''

So now we’ve completed the posterior portion of the procedure and we’re beginning the anterior portion by dissecting the bladder and vaginal wall to treat the cystocele. We begin by placing tension on the peritoneum and incising. We incise slowly and holding the peritoneum and use the pressure of the pneumoperitoneum to aid in the dissection. Here’s the uterus, the cervix here, and we begin to have access to the vagina here. Now you have to perform vaginal exploration to be sure it correctly delineates the space between the vagina and the bladder. By distending the vagina, you can clearly see its anatomical limits. You can see that the bladder is here. Without this distension, you can’t be sure that you’re in the right plane so it’s really mandatory to use this type of exposure to avoid injury to the bladder.

8. Anterior mesh placement 09'22''

Then you must expose the vaginal wall like so. Transfixing must be avoided here; you pass your needle, place it under tension to make sure that you have not performed the transfixation. Good vaginal bite here. We will now fix the mesh on the uterus to avoid the possibility of movement of the uterus between the pieces of mesh. So I have to have a good bite of mesh in the uterus. So I pull here and pass the needle into the vaginal wall like so. So here’s the posterior mesh, the anterior mesh and we have to fix them together.

9. Promontory fixation 11'48''

These are fixed to the sacral promontory with the stitch and you pull on the mesh to test your fixation, take out the needle; the knot is tied.

10. Peritoneal repair 12'24''

We start on the left side to close the peritoneal gap. I have achieved anterior protection on the right side and I go directly along the mesh channel to connect the posterior part of the dissection. Take the anterior part and this way, you can be sure that both meshes are lying flush in the channel and in the end you have no visible mesh. We just have to complete our suture lines here. Here’s the uterus, the mesh is under the peritoneum here, Douglas’s pouch was here and is now closed and the anterior part looks fine. Now we can close our abdominal wall incisions and you don’t need a drain.