Preoperative Preparation and Planning
An enterocele is a hernia in which the peritoneum and the intestinal contents displace the vagina, and can be a significant component of pelvic organ prolapse (POP) ( Fig. 90.1 ). Depending on the defect in fascial support, an enterocele may present in the anterior, apical, and/or posterior compartments. As such, an enterocele repair is often performed concomitantly with other surgical procedures for POP.
Enteroceles can develop from myriad etiologies, including prolonged increases in intraabdominal pressure, congenital conditions such as spina bifida, and iatrogenic causes after an anti-incontinence procedure or hysterectomy. Indications for surgical correction of POP are driven by patient symptomatology. Low-grade prolapse is often asymptomatic and does not warrant surgical correction. However, many women complain of a bothersome vaginal bulge, obstructive voiding symptoms or urinary retention, and/or constipation.
It is paramount to accurately determine the patient’s grade of prolapse, functional status, sexual activity, and degree of bother. These factors will influence the treatment decision. Prolapse repairs can include conservative management options such as a pessary or a surgical repair with either a restorative or obliterative procedure.
Nevertheless, when planning a corrective repair, several anatomic factors should be considered. A thorough pelvic examination should first be performed to classify the extent of the prolapse and to identify if there is an anterior, apical, and/or posterior component. High suspicion for an enterocele is necessary, as it is often difficult to determine exactly which organ(s) have prolapsed. However, patients rarely present with an isolated enterocele, and thus it is paramount to determine if there is concomitant apical prolapse ( Fig. 90.2 ). An isolated enterocele repair without re-suspension of the vaginal apex has been shown to increase the incidence of recurrent prolapse; hence, the vaginal apex should be resuspended at the time of prolapse repair. As such, this chapter will focus on apical repair options for POP. Isolated anterior or posterior defects may be treated with a site-specific repair (see Chapters 89 and 91 ).
Operative Procedures
Restorative Procedures
Abdominal Sacral Colpopexy
Indications for abdominal sacral colpopexy (ASC) include isolated enterocele and/or apical prolapse, a failed previous vaginal repair, or recurrence of an enterocele and/or apical prolapse. Younger women with an active lifestyle who wish to continue intercourse are also excellent candidates for ASC repair, as ASC maximizes the functional vaginal length and best approximates the natural anatomic angle of the vagina.
The ASC can be performed with a traditional open incision, a pure laparoscopic approach, or a robotic-assisted laparoscopic technique. The principles of the operation remain the same for each of these surgical means.
Access.
The patient is placed under general anesthesia and subsequently positioned in lithotomy. Care should be taken to pad all pressure points appropriately. The patient should be prepared according to standard sterile technique and a Foley is placed. For an open approach, a low transverse or midline incision may be used and a self-retaining retractor is placed for exposure. For a laparoscopic or robotic approach, abdominal access and pneumoperitoneum may be obtained by using either a Veress needle or the Hassan technique. Port placement is then performed in the standard fashion using either a “W” or “arch” configuration ( Fig. 90.3 ). Trendelenberg positioning can assist with small bowel reflection into the upper abdomen. The sigmoid colon is then gently mobilized toward the left lateral pelvis to visualize the sacral promontory.
Surgical Steps.
The ureters should first be identified. The sacral promontory is located medial to the right ureter and immediately caudad to the aortic bifurcation. Gentle palpation of the sacral promontory can assist in verifying the accurate location. The overlying peritoneal reflection is then incised, and the areolar tissue is dissected with care to identify the anterior longitudinal ligament of the sacrum. Extreme care should be taken to avoid both the middle sacral vessels and the presacral venous plexus. A 3–4 cm area anterior to the sacrum should then be dissected and cleared to directly visualize the shiny white longitudinal ligament ( Fig. 90.4 ). The sacral sutures may be preplaced at this time. Typically, a no. 0 nonabsorbable suture is used to place three interrupted sutures to secure the mesh to the anterior longitudinal ligament of the sacrum.
Direction is then turned to the vaginal cuff. A vaginal manipulator (end-to-end anastomosis sizer or malleable retractor) is placed within the vagina. The peritoneal reflection of the vaginal cuff is then carefully dissected ( Fig. 90.4 ). Caution should be used to avoid perforation of the vaginal epithelium. The bladder may be instilled with saline to assist in identification of this plane.
If there is a significant enterocele component, a traditional culdoplasty may be performed at this time. Several purse-string or linear sutures are placed into the enterocele sac to obliterate it.
Once dissection is complete, a small piece of T- or Y-shaped polypropylene mesh is then placed over the vaginal apex. The short arm of the mesh is placed over the vaginal cuff with the long arm directed toward the sacrum. The mesh is then sutured to the vaginal cuff with six to ten interrupted 2-0 nonabsorbable sutures.
To tension the mesh, the vaginal manipulator is advanced to the maximum cephalad position and then withdrawn gently to a neutral “sagging” position. The mesh is then secured to the anterior longitudinal ligament of the sacral promontory ( Fig. 90.5 ). Care should be taken to avoid excess tension—there should be slight laxity to the mesh once it is secure. Cystoscopy should then be performed to ensure ureteral patency and to confirm there is no mesh or suture material within the bladder. The mesh is then placed within the retroperitoneum by closing the presacral peritoneal tissue with a 2-0 absorbable suture. The fascia and skin are then closed in the standard fashion.
Transvaginal Apical Suspensions
Transvaginal apical suspension procedures are surgical options for an isolated enterocele or for apical prolapse with a concomitant anterior or posterior repair (see Chapters 89 and 91 ). A transvaginal suspension procedure is also an option for a woman with an elevated BMI or multiple previous abdominal surgeries who may not be a candidate for an ASC.
There are several options for a transvaginal apical procedure with or without an enterocele repair. The vaginal vault may be suspended to the sacrospinous ligament, the uterosacral ligament, or the iliococcygeus fascia. The sacrospinous suspension has been shown to have a higher rate of subsequent prolapse in the anterior compartment and an increased risk of damage to the pudendal neurovascular bundle. The iliococcygeus fixation procedure was created to address these issues but can contribute to vaginal foreshortening. The uterosacral suspension provides an overall more natural vaginal axis but has a higher rate of ureteral injury.
Incision
To begin the procedure, the patient is placed under general anesthesia and subsequently positioned in lithotomy. Care should be taken to pad all pressure points appropriately. The patient should be prepared according to standard sterile technique and a Foley is then placed. A self-retaining retractor such as the Scott ring and a weighted vaginal speculum can aid in exposure.
Enterocele Repair
Hydrodissection may be performed with injectable saline or lidocaine. The vaginal epithelium is then incised at the apex. The epithelium is carefully dissected away from the underlying structures. The dissection is carried out circumferentially to identify the pubocervical and/or rectovaginal fascia. Care is then used to palpate the prolapsing tissue and ensure no bowel is present. The enterocele sac is then incised ( Fig. 90.6 ). If an enterocele sac is not present, and thus intraperitoneal access is not possible, then an extraperitoneal vaginal vault suspension procedure is performed.
If intraperitoneal access is obtained, the abdominal cavity is carefully inspected for any pathology or adhesions. The bowel is then gently reflected and packed out of the surgical field with a moistened laparotomy sponge. Trendelenberg positioning can assist with obtaining adequate exposure. A retractor such as a Deaver is then used to elevate the bowel. A circumferential closure of the defect is then performed ( Fig. 90.7 ). A 2-0 suture is used to place a purse-string stitch around the base of the enterocele sac. This should extend up into the peritoneal cavity to ensure that the entire hernia sac is ligated. Extreme caution should be taken to avoid a bowel or ureteral injury. Repositioning the retractor intermittently can assist in suture placement. If the uterosacral ligaments are directly visualized at this juncture, then the ligaments may be incorporated into the purse-string repair. A second purse-string suture may also be placed. As the proximal purse-string stitch is tightened, a finger is placed into the peritoneal cavity to remove the laparotomy sponge and ensure there is not any bowel incorporated as the suture is tied.
Apical Repair Options
The central defect should first be repaired with 2-0 absorbable plication sutures to reapproximate the pubocervical and/or rectovaginal fascia. Steps are then taken to resuspend the vaginal vault with no. 0 double-armed, nonabsorbable suspension sutures.
Uterosacral Suspension.
For a uterosacral suspension, the suspension sutures should typically be preplaced into the bilateral uterosacral ligaments under direct visualization prior to closure of the enterocele sac ( Fig. 90.8 ). A pubocervical and/or rectovaginal fascial plication is then subsequently performed. The double-armed suture is then passed through this plicated fascia, and as the sutures are tied down, the apex is resuspended.
Sacrospinous Suspension.
In a sacrospinous fixation, the vaginal incision should be extended slightly to the posterior vaginal wall. The vaginal epithelium is then dissected from the underlying prerectal fascia. Blunt dissection is then performed to penetrate the pararectal fascia and enter to the pararectal space. The sacrospinous ligament is then palpated. The suspension suture is then placed into the sacrospinous ligament medial to the ischial spine by direct visualization or with a Capio transvaginal suture-capturing device (Boston-Scientific). The other suture arm is then brought through the plicated fascial tissue. The suture is tied down and the apex is resuspended.
Iliococcygeus Fixation.
In an iliococcygeus fixation, the vaginal incision should be extended slightly to the posterior vaginal wall. The epithelium is then dissected from the underlying prerectal fascia. Blunt dissection is then performed to penetrate the pararectal fascia and enter the pararectal space. The ischial spine and sacrospinous ligament are then palpated. The iliococcygeus ligament is just anterior to these structures. Once this is identified and palpated, the suspension suture is placed into the iliococcygeus fascia by direct visualization or with a Capio needle driver, and then brought through the plicated fascial tissue. The suture is then tied down and the apex is resuspended.
Closure
Cystoscopy should be performed prior to closure to ensure ureteral patency. The vaginal epithelium is then closed with a 2-0 absorbable suture and lubricated vaginal packing is placed.
Obliterative Procedures
Colpocleisis
A total colpocleisis is an excellent option for elderly patients with severe prolapse who are not sexually active, or who have multiple comorbidities and cannot undergo an extensive restorative repair. If the patient has a cervix, then a partial colpocleisis, or LeFort colpocleisis, may be utilized after documentation of a normal cervical examination. To begin the procedure, the patient is placed under general anesthesia and subsequently positioned in lithotomy. Care should be taken to pad all pressure points appropriately. The patient should be prepared according to standard sterile technique, and a Foley is then placed. A self-retaining retractor such as the Scott ring and a weighted vaginal speculum can aid in exposure.
Total Colpocleisis.
Hydrodissection may be performed with injectable saline or lidocaine with epinephrine. The vaginal epithelium is then incised 1–2 cm proximal to the urethral meatus and carried out to the prolapsed apex. The epithelium is carefully dissected away from the underlying pubocervical fascia and completely excised ( Fig. 90.9, A ). An anterior repair is then performed in the standard fashion using absorbable sutures. A perineorrhaphy incision is then made, and the remaining posterior vaginal epithelium is excised. A posterior repair is then performed in the standard fashion with absorbable sutures. The anterior and posterior repairs are then plicated together—the strength of the repair is in the creation of multiple layers. The levator fascia and, subsequently, the lateral vaginal epithelium are then sutured together with interrupted absorbable sutures to close the vagina ( Fig. 90.9, B ). Cystoscopy should be performed to ensure ureteral patency.
