LAPAROSCOPIC SACRAL COLPOPEXY

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.



SURGICAL TECHNIQUE



Operative Laparoscopy for Pelvic Organ Prolapse: Setup, Instrumentation, and Trocar Placement


Ideal stirrups for combined laparovaginal cases are the Allen stirrups and Yellofins (Allen Medical Systems, Acton, MA), which have levers that can quickly convert the patient from low to high lithotomy position while preserving sterility of the field. A sterile pouch attached to each thigh is equipped with commonly used instruments such as unipolar scissors, bipolar cautery, blunt-tipped graspers, bowel graspers, and suction irrigation.


The monitor screens should be placed lateral to the legs in direct view of the surgeon standing on the opposite side of the table. The scrub nurse should be centered between the two monitor screens that are used; otherwise, the scrub nurse is located behind one surgeon and the electrosurgical unit or harmonic scalpel on the opposite side. After the three-way Foley catheter and uterine manipulator (if needed) have been placed, the vaginal tray with cystoscope can be set aside for later use.


For standard suturing technique, needle holder preference is determined by comfort of the surgeon. Conventional and 90-degree, self-righting German needle holders (Ethicon Endo-Surgery, Cincinnati, OH) have ratchet spring handles, and the Talon curved needle drivers with spring handles (Cook OB/GYN, Spencer, IN) self-right the needle at an angle of 45 or 90 degrees to the needle driver shaft, depending on the style chosen. The Storz Scarfi needle holder and notched assistant needle holder (Karl Storz Endoscopy, Culver City, CA) are most like conventional needle holders used during laparotomy. However, the handles are difficult to maintain and may pop open after extended use. The needle holder tips may become magnetized, which hampers needle grasping. Disposable suturing devices that have been introduced include the Endo-stitch (U.S. Surgical Corp., Norwalk, CT) and the Capio CL (Microvasive Boston Scientific, Natick, MA; CL refers to Cooper’s ligament). Suturing devices are not recommended when performing laparoscopic sacral colpopexy because the depth of stitch placement in the vaginal muscularis is difficult to gauge tactically with these devices.


Extracorporeal knot tying is preferred because of technical facility and the ability to hold more tension on the suture, although some surgeons prefer intracorporeal suturing. When robotically assisted laparoscopic sacral colpopexy is performed, all suturing is done in an intracorporeal fashion. The choice of an open-ended or close-ended knot pusher for extracorporeal knot tying depends on surgeon preference. Our suture of choice is the single- or double-armed 1-0 Ethibond 36-inch suture on a CT-1 needle (Ethicon, Somerville, NJ). Our alternative choice for suture is 1-0 Gore-Tex (W.L. Gore and Associates, Phoenix, AZ). A 48-inch suture is preferred when suturing from ports at the level of the umbilicus. Sterile steel thimbles may be used by the surgeon or assistant when elevating the vagina while the surgeon is placing the stitches in the vaginal wall. However, vaginal manipulation when placing sutures is best achieved with endoanal anastomosis (EAA) sizers or fiberglass stents.

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Jun 4, 2016 | Posted by in ABDOMINAL MEDICINE | Comments Off on LAPAROSCOPIC SACRAL COLPOPEXY

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