Complications of these procedures include (i) erosions of graft material or suture material, which may be caused by graft or suture infection usually secondary to vaginal wall penetration, or performing the procedure adjacent to a vaginal incision, or securing the graft to an attenuated avascular wall with inadequate fibromuscular tissue (3.4%); (ii) significant intraoperative hemorrhage (especially in the presacral space) (4.8%); (iii) postoperative ileus, which may be secondary to the need for excessive packing of the bowel or to extensive Halban or Moschcowitz culdoplasty procedures (3.6%); (iv) small bowel obstruction, requiring reoperation (1.1%); (v) development of intra-abdominal adhesions with resultant pain and bowel dysfunction (unknown incidence); and (vi) wound complications, such as seromas and infections (4.6%) (120).
Several management techniques have been advocated to minimize these problems. Empiric ways to prevent graft erosions include (i) preoperative tissue optimization with vaginal administration of estrogen and treatment of vaginitis and infection of eroded areas; (ii) the use of small-gauge monofilament sutures placed in the fibromuscular tissue, thus avoiding full thickness passage; and (iii) excision of a portion of the vaginal apex when the vaginal wall is thin and depleted of its fibromuscular layer and vascularity. Graft attachment to “healthy” fibromuscular tissue rather than to thin avascular tissue should help prevent erosion. If such excision is necessary, or if the suspension is to be performed concurrently with a hysterectomy, good approximation of the fibromuscular layers above the mucosa, thorough irrigation, prophylactic use of antibiotics, and avoidance of graft placement across the suture line may decrease the likelihood of graft erosion. Choice of graft material may also be important. One would expect synthetic grafts to have greater durability than tissue grafts; however, erosion rates are more serious with the synthetic grafts. Anecdotally, some surgeons are convinced that less porous graft material, such as GORE-TEX, has a greater likelihood of becoming infected and eroding than do macroporous, filamentous polypropylene meshes. Numerous case series report serious episodes of hemorrhage from the presacral venous plexus (mean incidence 4.8%; range 0.18%– 16.9% of sacrocolpopexies requiring, at a minimum, transfusion) (121). This problem is less likely if dissection and graft fixation is limited to the level of S1 and S2 just caudad to the promontory and with the use of good light and meticulous dissection techniques to expose the anterior sacral ligament.
Careful tissue handling and packing technique may minimize postoperative ileus and adhesions. Incorporation of the sigmoid into a closure of the cul-de-sac posterior to the graft may also slow bowel function postoperatively. Small bowel obstruction has resulted from direct adhesive processes involving grafts to small bowel (120). Complete extra peritonealization of the graft using ﬂaps of peritoneum dissected from the prolapsed area and the peritoneum anterior to the sacral promontory and lateral to the right side of the sigmoid colon should prevent this complication. However, loops of bowel have been seen to prolapse through small defects in peritoneal closure with the same effect. Careful technique with adherence to basic surgical principles may help prevent this and other complications related to laparotomy.