Laparoscopic treatment of recurrent vaginal prolapse

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Laparoscopic treatment of recurrent vaginal prolapse

Authors

Keywords

prolapsus génito-urinaire,promontofixation

Media type

Surgical video

Duration

20'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1667.htm

Laparoscopic treatment of recurrent vaginal prolapse

1. Case presentation 00'10''

This video will demonstrate the laparoscopic management of vaginal prolapse. The case is that of a female patient who has previously undergone hysterectomy, who now presents with a voluminous vaginal prolapse associated with a grade 3 cystocele and a grade 2 rectocele.

2. Trocar placement and exposure 00'21''

The patient is placed in a Trendelenburg position, which helps the positioning of the small bowel loops. She seems to have a large sigmoid, which needs to be moved in order to create the right pelvic exposure.

3. Preparation of promontory and rectovaginal dissection 00'36''

We can now approach the area of the sacral promontory. The peritoneum is incised at this level. The white color of the pre-vertebral ligament is visible at this point. The peritoneal incision is then extended down towards the right uterosacral ligament, and the sigmoid mesocolon is maintained retracted to the left. Underneath the sigmoid mesocolon is a gutter onto which the anterior and posterior parts of the prosthesis will be attached. To the right, the essential landmark is the ureter, which should be preserved. The dissection is now continued horizontally up to the left uterosacral ligament crossing the rectum. The rectum is then identified and retracted cephalad with a grasper to open up the tissue planes. A vaginal ribbon retractor is then introduced in order to retract the vagina anteriorly. The dissection is then continued on either side down to the level of the levator ani muscles. It is important to identify the correct dissection planes and not to get lost in the ischiorectal fossa. At this point, a fifth trocar is introduced to maintain the cephalad sigmoid retraction. Gentle blunt dissection leads us to the plane of the muscle. We now approach the pelvic floor from the left side and the dissection is progressively continued on both sides. Again blunt dissection allows us to identify the muscle plane somewhat easier than on the right side. The perimysium comes into view now. We now move back to the right side and complete the dissection, which is made easier now that the levator has been reached on the left side.

4. Posterior mesh fixation 04'04''

Once the lateral dissection has been completed, the prosthesis is introduced. It has 2 inferior legs, which will be attached separately to each side of the levator ani with a stitch. The stitch must be placed deep into the muscle for the correct mechanical reinforcement. The rectum is retracted away from the needle by the assistant in order to prevent injury. Now the same on the left side. Once the fixation is complete, the medial portion is approximated to the posterior vaginal wall. The prosthesis is then fixed to the uterosacral ligament at the level shown. This ensures anterior angulation of the prosthesis away from the rectum. There is no stitch to the vagina, which has been retracted by the ribbon in order to identify the vesicovaginal plane.

5. Vesicovaginal dissection 05'30''

As this patient has a large cystocele, the vagina is covered by the bladder. The dissection is continued using the ultrasonic scissors anterior to the vagina in the vesicovaginal plane. It is important not to perforate the vagina as this would greatly increase the risk of infection of the prosthesis. Injury to the bladder is less serious although it has to be identified and repaired immediately. The dissection is continued so long as it is easy to perform and there are no vascular structures which hinder it. Now the dissection becomes a little bit more difficult.

6. Anterior mesh fixation 06'34''

We now seem to have enough length to attach the anterior prosthesis to the anterior surface of the vagina. The anterior prosthesis is V-shaped and its tip is fixed to the vaginal wall at this point. It is important not to transfix the vagina with the needle. Once this knot is secured, a running stitch is placed to approximate the left part of the prosthesis with the vagina. The anterior and posterior prostheses are then approximated with the vagina in between. This prevents any tissue entering in between, which can cause recurrence of the prolapse. The fixation is continued along the whole of the left border of the vagina. A similar stitch is placed on the right side.

7. Promontofixation 08'08''

Now to the proximal fixation of the prosthesis to the promontory. A good bite is taken of the pre-vertebral ligament and then, first the posterior, and after the anterior prosthesis are fixed all in one. An extracorporeal knot is slid down using a knot-pushing device. The knot is reinforced with further intracorporeal sutures. Any excess prosthetic material is trimmed at this point and removed from the abdominal cavity.

8. Repair of peritoneum 09'00''

After a quick check, the peritoneum is closed over the dissected pelvic floor. In this patient, it is rather difficult due to the excessive sigmoid loop. There is still a slight defect. The sigmoid loop is simply placed in the pelvis to cover the remaining peritoneal defect. No drains are required after this procedure and this is the end of the operation.