As with most pelvic operations, sacrocolpopexy has been successfully accomplished by the laparoscopic and robotic route and has the potential to offer patients the benefits of less postoperative discomfort and faster recovery as well as potential lower risks for adhesions and ileus. Outcomes depend on the expertise and experience of the surgeon; “cutting corners” to shorten the procedure could affect anatomical success. The applicability of the laparoscopic technique is limited by the need for a relatively high level of technical skill. In the authors’ experience, ipsilateral suturing (through same sided ports) is preferred to contralateral suturing. The authors have also found that straight self-righting needle drivers and non-self-righting curved needle drivers are useful in attaching the mesh to the vagina. The Carter-Thompson suturing device is sometimes helpful to aid in elevating the sigmoid colon away from the pelvic cul-desac by tagging the peritoneal edge. The robot has provided an easier platform for a minimally invasive approach to the sacrocolpopexy. Data about its use are limited to several case series that demonstrate comparable short-term results with open and laparoscopic techniques (121).
For sacrocolpopexy, whether through laparotomy or laparoscopy, the pelvis should be completely exposed with the lower sigmoid colon stretched cephalad (Fig. 27.14).
1.
With a vaginal obturator (an EEA sizer) placed vaginally to visualize the area that is not covered by the bladder or rectum, the peritoneum is dissected from the underlying vaginal fibromuscular layer anteriorly to bladder reﬂection and posteriorly at least to the level of the sigmoid rectal junction, creating bilateral peritoneal ﬂaps. Laterally, vascular bundles are visible.
2.
Two separate loosely woven polypropylene mesh grafts are shaped similar to boat paddles. The “paddle” portions are shaped to cover the areas anterior to the apex and posterior to the apex, respectively, and the “handles,” which are approximately 8 to 10 cm in length and 1 cm wide, are anchored to the anterior sacral ligament. The paddle portions are secured circumferentially to the fibromuscular layers anteriorly and posteriorly with six to eight monofilament 3-0 nylon sutures and one or two sutures placed centrally (Fig. 27.14A).
3.
When the fibromuscular tissue in the area is attenuated, a portion of the vaginal wall is excised and closed, as noted previously.
4.
The peritoneum overlying sacral vertebrae 1 and 2 is incised while retracting the sigmoid colon to the left, and careful dissection is employed down to the anterior ligament. Care is taken to stay well medial to the right ureter and hypogastric vessels.
Figure 27.14 Sacrocolpopexy. A: Illustrates (i) graft attachment to the posterior area of prolapsed vagina to or below the rectal-sigmoid junction after the overlying peritoneum has been dissected and ﬂapped laterally and (ii) exposure of the presacral space with suture placement through the anterior sacral ligament. An appropriately shaped second graft is placed anteriorly.
B: Illustrates attachment of both grafts without tension to the sacrum. Prevention of subsequent enterocele and/or sigmoidocele is accomplished by box closure of the cul-de-sac peritoneum lateral to the left side of the sigmoid, attachment of the presigmoid fat to the graft centrally, and reperitorealization of the graft through the right side of the cul-de-sac. EEA, end-to-end anastomosis sizer. (Redrawn by J. Taylor.) 5.
Hemoclips are placed caudad and cephalad on the middle sacral vessels if it is felt that this will allow more optimal suture placement. The peritoneal incision is extended into the right cul-de-sac area adjacent to the sigmoid.