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

  • 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.
  • 00'18" Introduction and case report
    It’s a 76-year-old woman and she had previously surgery in 83, it was a Burch procedure for incontinence, stress incontinence. Now she has a huge incontinence again, and a prolapse, which is a cystocele grade 2, and a rectocele grade 2. When you push the cystocele, you have a worsening of the incontinence.
  • 00'58" Patient set-up
    So just for the installation, immediately when the patient is under anesthesiology, we place the patient a Trendelenburg position, at about 30 degrees; then during the preparation, during the placement of everything, then the bowel will go in the abdominal cavity and the pelvis will be emptied of the bowel structure. What is also important is to have both arms along the body, it will make the operation easier, otherwise you would have to work with the shoulder at this level. It’s very important to work at the level of the patient’s head. Another important thing is to have good access to the vagina because you must place the vaginal blade, and the bottom must be at the outside of the table at about 5cm, to be able to do a good mobilization. I will show you the blade, we place on it a glove, and we have to do a flexion of the blade, and now I can show you the movement of the blade to expose. If you don’t have a correct patient placement, you can’t do a mobilization of the blade.
  • 02'22" Beginning of procedure
    So now we start the procedure by doing the insufflation. You can see here that the abdomen is really symmetric, and the insufflation is really well. And you see now, I have pressure, the maximum pressure is 12mmHg. I just wait, and now when I have a good pressure, we will place four ports, the first one is a 10mm port, and three other 5mm ports. The 3 ports will be quite on the same line; the first one will be on the iliac fossa on the right side for me, at about two or three fingerbreadths inside the iliac crest. The second one will be medial on the midline in between the pubic bones and the umbilicus, and the third one will be exactly symmetric on the other side, for my assistant. I must say that I am left-handed that’s why I’m working on the right side but that’s exactly symmetric if you’re left-handed. You can clearly see inside the epigastric vessel, so I’m outside of them, and when you introduce your ports, you introduce them in the side of the surgery. You see the three ports on the same line and now we are ready to start, so the first thing is just to finish the installation of the bowel, you can see just with a little movement, normally it’s enough to create.
  • 04'16" Exposure and identification of sacral ligament
    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.
  • 06'47" Peritoneal incision and inter-rectovaginal dissection
    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.
  • 11'15" Pelvic floor exposure
    Here, I am at the level of the anus, and I can’t go on more. It’s sticky here. So when you are here, you just go laterally on both sides. I will start with the left side, I will go laterally, push away the rectum, and find just laterally here the little hole to find the pelvic floor. What is important is to let all this inferior attachment which represent the vascularisation of the rectum, because if you start from here, if you release all this, then you have bleeding, and also you can have neurologic lesions, and you can have constipation problems after the surgery. Now exactly on the symmetric aspect, we’ll go laterally you see, I just push away the fibers, I go from outside to inside, because to be away from the rectum muscle, and slowly I release the little adhesion to find the good plane. And now you can clearly see the pelvic floor again really clearly here, because I want to fix my mesh here at the level of the anus, and to avoid crossing the rectum, as we were doing ten years ago because we were fixing the mesh at this level several years ago, and now we are fixing the mesh at this level to avoid any crossing, and it helps for the patient’s outcome.
  • 13'07" Fixation of the posterior mesh
    We will start by the first mesh, so these meshes are polyesther meshes, we introduce them using a 10mm port. Now we’re ready to start. So you see the mesh is just posteriorly placed and now you have to fix it at the level of the muscle. You see here clearly the muscle, you go and you have to be outside. See it’s clearly a good fixation and just a fixation. So it’s a non-resorbable stitch, it’s Mersuture® 2/0 and the stitch is 26mm. So the second stitch is exactly symmetric on the other side. You arrive at the level of the rectum and you just go through the muscle. So the mesh will go in this little hole; we described some ulceration several years ago at the beginning of the experience, and it was always posterior ulceration probably due to the bad vascularization of this side. And now we’ll fix the upper part of the mesh on the uterosacral ligament so I have to place my points a little bit down to avoid the vaginal cul-de-sac somewhere here and here the large part of the mesh at this level. And the last point on the other side and now the uterosacral ligament somewhere here. So we’ll just check to see if everything is OK, just to show you that the rectupm is absolutely not taken by the mesh.
  • 15'37" Beginning of posterior peritonization
    Now i’ll show you the anterior mesh. It’s a mesh with 2 legs because we’ll have to pass through the ligaments, you’ll see. I let the mesh at the back of my fields and then I’ll be able to start thereafter under the mesh. So we start just to close the Douglas’ pouch because at the end of the surgery when both meshes are placed and fixed, it’s difficult to close this area. So I’ll start just now and I’ll let my stitch in the field. You see I take the entire Douglas’s pouch, and now I’m going to the right side on the right ligament doing a purse-string with a running suture to close. And this stitch closes Douglas’s pouch totally. And just now we’ll just prepare the next step; just to fix the peritoneum at this level somewhere here. Becuase you have to imagine that it’ll go here to close this right ligament so I lift the needle here and we’ll now do a passage through the ligament. And I just want to follow the peritoneum to go in the anterior space on the Retzius’ space and on this side.
  • 17'38" Anterior inter-vesicovaginal dissection
    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.
  • 19'57" Fixation of the anterior mesh
    So I’ve to take the mesh at this level. The first point will be very medial and here you have to be really superficial and I like to do several little stitches to fix it but you must away from the bladder to avoid any fixation of the bladder and the mesh because you can have ulcerations. I have seen three and you can have several months or years after an ulceration. And you see here I like to cut the thread really short so you see now my assistant will just move the blade and I’ll go laterally to fix it. So we’ll take the large port and now these points are also very important. These are the fixations at the level of the isthmus; so here you can see I’ll start at the large of the mesh here at the upper part. Then immediately I’ll fix the anteror cul-de-sac of the vagina. Now my assistant is holding. I’ll fix the uterus at the level of the isthmus to have a strong fixation. And the last point will be exactly the same on the other side for esthetic considerations. Now we’ll fix the mesh. We’ll pass the 2 legs on both sides. And we do exactly the same on the other side.
  • 22'20" Fixation to the sacral ligament
    Now the last point is on the sacral ligament. See I introduced the end of the stitch by the 10mm port. I now take it out by the 5mm port and then I’ll do just a traction to place the stitch inside. You’ll see. Then I have already one thread in the 5mm port medially. Now I’ll pass through the ligament and through the mesh and go out exactly on the same port to be able to do a knot. I’ll do an extracorporeal knot—I’ll show you. So the first mesh will be the posterior one without any tension, and just place as it goes. And then to treat the cystocele, I like to do little tractions on the mesh, on the anterior one. So just look at the cystocele. You can see it. Here it’s fine, no more traction, just at this level; and now my assistant will help me hold the mesh. And the last one exactly symmetric; my assistant holds everything. Now because I have to pass through a 5mm port, I have just to use a straight needle to be able to take it out. Now you can see the knots coming immediately. I do another one just to block it but normally it’s enough.
  • 24'18" Peritonization and end of procedure
    And now you see we’ve just to take the previous stitch. Just now you see I have to close this window. Here’s the isthmus, and just take the peritoneum, and you see just with this fixation. See now because of the releasing of the peritoneum, everything is closed and I have just to finish and this is why it’s so important to do a large incision and now it’s really easy to finish. And now you’re sure you have a total peritonization, very well done and without any tension. Sometimes, the first months, patients can have some constipation due to the dissection. See we don’t place any drain because there is no bleeding and we never use any suction most of the time. I think it was a good live demonstration. Thank you for your attention.
  • Related medias
    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.