Chapter 72 LAPAROSCOPIC SACRAL COLPOPEXY

Laparoscopic sacral colpopexy was first reported by Nezhat and colleagues in 1994.¹ Adoption of this procedure has increased in the past decade and has evolved to include robotic assistance. The possible advantages of laparoscopic surgery are improved visualization of anatomy of the peritoneal cavity because of laparoscopic magnification, insufflation effects, and improved hemostasis; shortened hospitalization resulting in potential cost reduction; decreased postoperative pain and more rapid recovery and return to work; and better cosmetic appearance of smaller incisions. Disadvantages of laparoscopic surgery include a steep learning curve in acquiring suturing skills, technical difficulty of presacral dissection, increased operating time early in the surgeon’s experience, and possibly greater hospital cost because of increased operating room time and the use of disposable surgical instruments. These disadvantages, inadequate experience in advanced laparoscopy in residency and fellowship programs, surgeon preference for vaginal route surgery, and recently introduced minimally invasive apical suspension procedures have thwarted widespread adoption of laparoscopic surgery for pelvic organ prolapse.

The indications for laparoscopic vaginal apex prolapse and enterocele repair are identical to those for vaginal and abdominal routes. The choice of laparoscopic route is determined by the preferences of the surgeon and patient and by the laparoscopic skill of the surgeon. Additional factors that should be considered include history of pelvic or anti-incontinence surgery, previous failed transvaginal colpopexy, short vagina, severe abdominopelvic adhesions, the patient’s age and weight, the need for concomitant pelvic surgery, and the patient’s ability to undergo general anesthesia.

The technique of laparoscopic sacral colpopexy described in this chapter follows standard procedures for operative laparoscopy for access and is identical to the more proven open abdominal sacral colpopexy (see Chapter 73). Clinical outcome and complications are summarized.

ANATOMY

Thorough knowledge of the anatomy of the anterior abdominal wall is mandatory for safe and effective trocar insertion. The umbilicus is approximately at the L3-to-L4 level, and the aortic bifurcation is at the L4-to-L5 level. In obese women, the umbilicus is caudal to the bifurcation. The intraumbilical trocar should be introduced at a more acute angle toward the pelvis in thin women and closer to 90 degrees in obese women. The left common iliac vein courses over the lower lumbar vertebrae from the right side and may be inferior to the umbilicus. Common iliac arteries course 5 cm before bifurcating into the internal and external iliac arteries. The ureter crosses the common iliac artery at or above its bifurcation.

The superficial epigastric artery, a branch of the femoral artery, courses cephalad and can be transilluminated. The inferior epigastric artery branches from the external iliac artery at the medial border of the inguinal ligament and runs lateral to and below the rectus sheath at the level of the arcuate line. It is accompanied by two inferior epigastric veins.

When considering the anatomy of the repair of pelvic organ support, a surgeon must keep in mind the three levels of support of the vagina described by DeLancey in 1992.² The upper fourth of the vagina (level I) is suspended by the cardinal-uterosacral complex, the middle half (level II) is attached laterally to the arcus tendineus fasciae pelvis and the medial aspect of the levator ani muscles, and the lower fourth (level III) is fused to the perineal body. The endopelvic fascia laterally blends with the muscularis of the vagina. All pelvic support defects, whether anterior, apical, or posterior, represent a break in the continuity of the endopelvic fascia or vaginal muscularis and a loss of its suspension, attachment, or fusion to adjacent structures. The goals of pelvic reconstructive surgery are to correct all symptomatic defects, thereby reestablishing vaginal support at all three levels, and to maintain or restore normal visceral and sexual function.

The key anatomic landmarks of sacral colpopexy are the middle sacral artery and vein; the sacral promontory with anterior longitudinal ligament; the aortic bifurcation and the vena cava, which are at the level of L4 to L5; the right common iliac vessels and right ureter, which are at the right margin of the presacral space; and sigmoid colon, which is at the left margin. The left common iliac vein is medial to the left common iliac artery and can be damaged during dissection or retraction. The sacral foramina are only 1 to 1.5 cm from the midline, and the sympathetic chain is lateral. The ureter, which crosses over the common iliac artery bifurcation and courses along the pelvic sidewall, is approximately 1 to 1.5 cm lateral to the uterosacral ligament as it passes underneath the uterine artery.

The anatomic landmarks during laparoscopic sacral colpopexy graft attachment are the pubocervical fascia (i.e., anterior vaginal muscularis with overlying endopelvic fascia) and the rectovaginal muscularis (i.e., fibromuscular layer of the posterior vaginal wall above the rectovaginal septum). The rectovaginal septum is ideally the posterior point of attachment of the sacral colpopexy mesh, allowing continuity with the perineal body.