OPEN ABDOMINAL SACRAL COLPOPEXY

Chapter 73 OPEN ABDOMINAL SACRAL COLPOPEXY



Chi Chiung Grace Chen, Marie Fidela R. Paraiso


Pelvic organ prolapse is a condition that physicians are likely to encounter as women are living longer and more emphasis is placed on maintaining their physique and capacity for sexual activity. It has been estimated that more than 300,000 surgeries are being performed annually to correct pelvic organ prolapse at a cost of greater than $1 billion dollars.1 The number of women seeking attention for these disorders is projected to increase by 45% in the future.2


Management of pelvic organ prolapse depends on the goals and expectations of the patient and on the patient’s comorbidities. For example, women who have minimal symptoms or those with prolapse that does not extend beyond the hymen may benefit from pelvic floor exercises and behavioral modifications. Patients who have many comorbidities and are poor surgical candidates may benefit from vaginal pessaries. Women who do not desire preservation of sexual capacity may benefit from a less morbid obliterative procedure, such as colpocleisis. When contemplating the surgical correction of pelvic organ prolapse, the surgeon must also consider the existence of other support defects and any dysfunction of bladder or bowel. The surgeon must decide whether to approach these repairs abdominally, vaginally, or laparoscopically. In this chapter, we will focus on abdominal sacral colpopexy or suspension of the vagina to the sacral promontory, which is considered the gold standard procedure for correcting pelvic organ prolapse.


Abdominal sacral colpopexy should be considered if the patient has severe vaginal apical prolapse and requires concomitant pelvic or anti-incontinence surgery by the abdominal route. Other indications include previous failed transvaginal colpopexy, foreshortened vagina, weakened pelvic floor, and chronic increases in abdominal pressure as a result of medical comorbidities (e.g., chronic obstructive pulmonary disease, chronic constipation) or occupation (e.g., heavy manual labor). Some pelvic surgeons also prefer abdominal sacral colpopexy for young patients with severe apical prolapse.



“GENERAL INTRAOPERATIVE PRODURES” TO “ANATOMY AND GENERAL INTRAOPERATIVE PRODURES”


As the relevant abdominal and pelvic anatomic landmarks for open sacral colpopexy are the same as for laparoscopic sacral colpopexy, please refer to Chapter 72. Furthermore, some general intraoperative considerations are also the same and include placement of the patients in low lithotomy position under general anesthesia, prophylactic intravenous antibiotics before initiation of surgery, pneumatic compression stockings on the patients’ lower extremities, and placement of a 16-Fr three-way Foley catheter to continuous drainage with the irrigation port attached to sterile water or saline to facilitate retrograde filling of the bladder to assist in dissection of the bladder off the vaginal apex during surgery.



SURGICAL TECHNIQUE



General Intraoperative Procedures


Specifically, the ideal stirrups for combined abdominovaginal 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 transverse or vertical laparotomy incision is made based on surgeon preference or concomitant procedures. For obese patients, a Maylard incision may be useful for improved exposure compared with a Pfannenstiel incision.


The patient is placed in a Trendelenburg position. The small bowel is packed upward, and the sigmoid colon is packed to the left paracolic gutter. The Bookwalter retractor or Balfour retractor is placed to hold the sides of the incision open, giving exposure to the operative field. The Bookwalter retractor is ideal for obese patients. Sterile towels are placed below the lateral points of the Balfour retractor to decrease compression of the psoas muscle, safeguarding against femoral neuropathy.


The sacral promontory is palpated, and the respective landmarks of the presacral space are delineated. The presacral peritoneum is tented and incised down to the level of the posterior cul-de-sac. The peritoneum may be retracted laterally by placing tagged 2-0 absorbable sutures, which can be tied together after the procedure is complete for closure of the peritoneum. Alternatively, a tunnel can be made in the right pararectal peritoneum from sacral promontory to the posterior cul-de-sac rather than completely incising the peritoneum. Kittners (i.e., endoscopic, blunt dissectors with radiopaque tips) are used to clear away the areolar tissue of the sacral promontory, delineating the anterior longitudinal ligament of the sacrum and the middle sacral vessels. Care must be taken to avoid trauma to the presacral vessels because these vessels retract easily, and life-threatening hemorrhage may ensue. If bleeding does occur, pressure, hemostatic clips, cautery, fibrin glue, and Gelfoam may be applied. If these measures are not successful, bone wax and sterile thumbtacks should be used. The presacral nerve should be preserved to decrease the risk of temporary postoperative urinary retention and constipation.


Manipulators are placed in the vagina and rectum for delineation. For example, fiberglass obturators or endoanal anastomosis (EAA) sizers may be placed in the vagina and rectum for traction in opposite directions to delineate the rectovaginal space. The peritoneum is incised, rectovaginal space entered, and blunt dissection performed along the length of the posterior vaginal wall. In cases of abdominal sacral colpoperineopexy, this dissection is extended to the perineum. The bladder is filled with 300 mL in a retrograde fashion with a three-way Foley catheter hooked to irrigation to delineate the superior border of the bladder. The bladder peritoneum is incised, and the bladder is sharply dissected downward to the bladder base off the vagina. Palpation of the Foley catheter bulb aids in this dissection. Care should be taken not to cauterize the bladder and vagina to a great extent. Peritoneum should be preserved at the vaginal apex if possible to decrease risk of mesh erosion.


After dissection of the bladder and preparation of the rectovaginal space, several rows of 1-0 nonabsorbable suture are stitched into the posterior vaginal muscularis. The most distally placed sutures are at the perineum during colpoperineopexy. The stitches should be placed at least halfway down the length of the posterior vagina for a sacral colpopexy. It is preferable to avoid through-and-through stitches into the vaginal epithelium. Each row of sutures should be placed 2 cm apart. The sutures are tagged, and after all sutures are placed, the ends of the suture are brought through the pores of a 4 × 15 cm polypropylene mesh. Polypropylene suture is easy to work with in this setting; when cut, it is easily passed through the pores. A longer piece of polypropylene mesh is required for the sacral colpoperineopexy. The sutures are then tied without strangulating the tissue to decrease erosion. If a Halban or Moschcowitz procedure is performed to obliterate the pouch of Douglas, these sutures can be placed before or after posterior mesh placement, but they should not be tied until the posterior mesh is placed. A 2-0 nonabsorbable suture is adequate for the culdoplasty procedures.


Approximately two or three rows of 1-0 nonabsorbable suture are placed on the anterior vaginal wall. The ends of the sutures are then brought through the pores of a second 4 × 15 cm piece of polypropylene mesh and tied. The vaginal manipulator is used to place the vagina under no tension in the right pararectal space. The securing point of the mesh to the anterior longitudinal ligament at the S1 or S2 level is then marked. Two or three polypropylene sutures are placed transversely into the anterior longitudinal ligament. The suture ends are then brought through the pores of both leafs of mesh so that each leaf can be secured without tension.

Related posts:

DEVELOPMENTAL ANATOMY AND UROGENITAL ABNORMALITIES USE OF CADAVERIC FASCIA FOR PUBOVAGINAL SLINGS ANTERIOR COLPORRHAPHY FOR CYSTOCELE REPAIR TRANSVAGINAL CLOSURE OF THE BLADDER NECK IN THE TREATMENT OF URINARY INCONTINENCE FEMALE SEXUAL FUNCTION AND DYSFUNCTION FUNCTIONAL ANATOMY AND PATHOPHYSIOLOGY OF PELVIC ORGAN PROLAPSE

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

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