Abdominal Sacrocolpopexy

Abdominal sacrocolpopexy is considered by many to be the gold standard procedure for repair of vaginal vault prolapse. The resultant vaginal axis is the most physiologic of all reconstructive procedures. Because this procedure is performed through an abdominal incision, its associated morbidity is greater than with the vaginal approaches. Therefore, it is typically reserved for women in whom sexual activity is of great importance. The goal of the procedure is to elevate the vaginal apex with a mesh bridge to the sacral promontory (Figure 8-2.3). The procedure is begun through a transverse or vertical laparotomy incision. We place the sacral promontory sutures first, before

Figure 8-2.3. Abdominal sacrocolpopexy involves elevation of the vaginal apex to the sacral promontory with a mesh bridge. (Reprinted with the permission of The Cleveland Clinic Foundation.)

any vaginal manipulation. We open the peritoneum overlying the sacral promontory using the right ureter and the colon as the lateral landmarks for identifying the peritoneum to be incised. The dissection is then followed vertically to an area above the sacral promontory and down to the pelvic floor musculature inferiorly. Sharp and blunt dissection is then used to dissect fatty and connective tissue off of the sacral promontory. Once the anterior vertebral ligament is seen, the dissection is complete. Multiple vessels including the middle sacral artery and periosteal perforators are typically seen overlying the sacral promontory. To avoid significant bleeding, we use bone anchors for attachment of the sacral suspensory sutures. Life-threatening hemorrhage has occurred during suture placement at this location. Therefore, rather than elevating portions of the ligament with sutures, bone anchors minimize trauma because of the presence of a single puncture site (Figure 82.4). Either a drilled or a pressed in bone anchor can be used for this purpose. The currently available bone anchors have a monofilament #1 Prolene suture attached to the bone anchor. Once we have placed the two bone anchors on the sacral promontory, we will then address the vaginal apex. Rather than using a vaginal obturator, I prefer to place my fingers within the vaginal canal in order to be able to identify both vaginal apices. This is important for later approximation of the uterosacral ligaments in an abdominal McCall fashion to prevent development of an entero-cele. We use Prolene mesh folded over and fashioned into a "Y"shape such that the longer arm extends along the posterior vaginal wall to the level of the rectal reflection. Ante riorly, the bladder is dissected off of the vaginal wall for a distance of a few centimeters for attachment of the short arm of the mesh. It is of great importance to identify any fascial tears along the anterior or posterior vaginal walls before placement of the mesh. These are typically seen as segments of fascial tissue that have separated from the vaginal apex. The edges should be sutured to the vaginal apex with permanent suture before placing the suspensory mesh. We will then use three rows of two 2-0 Prolene sutures along the posterior vaginal wall and one row of two 2-0 Prolene sutures along the anterior vaginal wall. Once the Prolene mesh has been secured to the vaginal walls, the abdominal McCall procedure is performed approximating the uterosacral ligaments in the midline. This part is important in prevention of the development of a posterior enterocele. The mesh is then elevated to the sacral promontory such that it is placed in a tension-free manner to suspend the vaginal apex. Once the mesh has been attached to the sacral promontory, the area is reperitonealized making sure to cover the entire mesh for the prevention of any internal hernias. If additional reconstructive procedures are performed, they are then performed at this time; typically including abdominal paravaginal and vaginal rectocele repairs.

It is important to maintain continuity of the endopelvic fascia with the Prolene mesh used for the sacrocolpopexy. This will allow for continuity of fascial envelope or mesh from the perineum to the vaginal apex both anteriorly and posteriorly (Figure 8-2.3).

It is important to note specific pre- and postoperative care required by the patient undergoing a sacrocolpopexy. We use preoperative mechanical bowel preps in all of our patients who undergo this surgical procedure to facilitate bowel packing and improve visualization of the sacral promontory. Postoperatively, we advance the patient's diet very slowly because there is an underlying risk of ileus,

Figure 8-2.4. Use of bone anchors for abdominal sacrocolpopexy minimizes the amount of periosteal trauma and risk of hemorrhage.
Figure 8-2.5. Laparoscopic vault suspension can be performed using the uterosacral ligaments and extracorporeal knot tying.

which can be quite problematic if the patient is fed too quickly. Our patients typically stay in the hospital for 3 to 4 postoperative days.

We attach the suspensory mesh to the sacral promontory rather than to S2 or S3 as has been described by others. This results in easier placement of the bone anchors through the anterior sacral ligament. This does not seem to result in an excessively vertical vagina, or any significant long-term difficulties.

In a recent series of 46 patients who underwent bone-anchored sacrocolpopexy using Prolene mesh at our center, we had no recurrences of vaginal vault prolapse.5 We noted one rectocele, but no cystoceles. Mean blood loss was 213 mL (range, 100-500). We had one mesh erosion, which responded to conservative therapy. We use local estrogen cream postoperatively in all of our patients to maintain mucosal integrity.

Constipation Prescription

Constipation Prescription

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