Surgical tutorial: laparoscopic prolapse repair
Epublication WebSurg.com, Sep 2010;10(09). URL: http://websurg.com/doi/lt03enlee001
In this lecture, Dr. Ted Lee, MD, director of the department of minimally invasive gynecologic surgery in Pittsburgh, Pennsylvania, USA, focuses on the sacrocolpopexy procedure in relation to his experience in the treatment of genital organ prolapse. He highlights some important key steps of the procedure, together with some tips and tricks on optimizing exposure, facilitating dissection, suturing of the mesh and how to minimize complications. The first step of the procedure is an adequate exposure with bowel retraction in order to have sufficient space to work in the sacral promontory area. The next step is the rectovaginal dissection, with caution to keep the dissection close to the vagina, leave enough adipose tissue to the rectum, and dissect the pararectal spaces until the levator ani muscles. Dr. Lee stresses the fact that the depth of the dissection depends on the posterior wall defect. So in patients with a posterior defect not protruding outside the hymen, the dissection should stop at the level of the midvagina. This is in order to avoid future constipation with deep dissection. Only in patients with large posterior wall defects, the dissection should be performed at the level of the levator ani. Dr. Lee indicates some surgical instruments, such as the rectal probes and retractors, that are useful for the dissection of the rectovaginal space. Next step is the vesicovaginal dissection, which can be very challenging, especially in patients with previous hysterectomy. Some tips and tricks such as the use of a Foley catheter or the use of a large probe to distend the vagina in order to facilitate dissection are demonstrated. Next is the presacral dissection with skeletonization of the fibrofatty tissue, dissection from right to left to preserve the hypogastric nerve, and identification of a good plane of dissection to avoid bleeding, especially from the left common iliac vein, but also from sacral vessels, which can be dissected. The last step is the suturing of the mesh. He explains that there is no longer the need to use non-absorbable sutures together with the use of tackers in order to secure the mesh to the sacrum without complications. A nice technique of suturing and knotting is demonstrated during mesh peritonization. Finally, in patients where the uterus needs to be preserved for fertility purposes (sacrohysteropexy), Dr. Lee explains an alternative method to place the mesh medial to the uterine vessels in order to perform, if need be, a hysterectomy more easily later on. He also demonstrates a nice uterosacral suspension technique used in patients who do not wish to be treated with a mesh for their prolapse.