Laparoscopic sacropexy: Laparoscopic sacropexy: an approach to pelvic an approach to pelvic

prolapseprolapseJean Pierre Giolitto, M.D.Polyclinique les Bleuets REIMS - France

SWISS-ENDOS December 2004

Introduction19921996 strict reproduction of the technique by

laparotomy.19962000 innovative aspects

new anatomic spacesendoscopic vision

pneumo dissection20002004 simplification of the technique

reproducibility with acceptable operating timeexcellent results with anatomical correction and good functional results

Preoperative evaluationEvaluation of the prolapse

degree of prolapse: uterusbladderrectumenterocele

cystocele

central: break of vesico vaginal fascia, vaginal rugae absent

lateral: vaginal rugae present

higher rectocele (fascia detachment)

lower rectocele (deficient levator ani muscle)

Preoperative evaluationEvaluation of the (in)continence

clinical examinationurodynamic investigation prolapse plus pure SUI prolapse and hidden SUI prolapse without urinary problem

Evaluation of the rectal dysfunctionconstipation

fecal or gas incontinence

Evaluation of the enterocele

MRI

Preoperative evaluation

Evaluation of the feasibility of laparoscopy general anesthesia with pneumo peritoneum Trendelenburg position older and obese patients the vaginal route will not be forgotten

Preoperative preparation

Bowel preparation empty the bowel and enlarge operating space low residual diet 4-5 days prior to surgery local enema one day before

Vaginal oestrogens3 or 4 weeks before

Vaginal and parietal disinfection

Preoperative assessment Clinical reexamination under general anesthesia

search for new information which might modify the strategy Morphology of the abdominal wall

position of trocars pubis – umbilicus distance first trocar Ø 10mm: umbilical or supra umbilical one 5 or 10mm trocar suprapubic on midline; at

least 6cm between 1st and 2nd two 5mm lateral trocars at level of anterior superior

iliac spines

Preoperative assessment

Exposition of the operating field fixation of the uterus to the anterior abdominal

wall fixation of the bowel: sigmoid colon to the left

abdominal wall

Use a 5 or 6cm straight needle with a nylon suture

Operating strategy Dissection

promontory: peritoneum to the Douglas

rectovaginal space

( hysterectomy)

anterior bladder dissection Reconstruction

first posterior mesh with culdoplasty with immediate peritonization

second anterior mesh fixation to the promontory complete reperitonization

Operating strategyDissection of the promontory

Trendelenburg position level L5-S1 anterior vertebral ligament good care should be taken regarding to

left iliac vein right ureter median sacral artery and vein

lower bifurcation of aorta and obese patients

Incision of the right lateral peritoneum : vertical dissection to Douglas pouch particular attention should be given to the right ureter

Operating strategy

Dissection of the rectovaginal space opening of the peritoneum of the Douglas pouch

between the two uterosacral ligaments dissection downwards to the posterior vaginal

wall identify the rectum and the laterally levator ani

muscles use vaginal retractor

Operating strategyFixation of the posterior mesh

both lateral sides levator ani muscles – 2 or 4 non absorbable sutures

medially and laterally fixation of the mesh to the vaginal wall without transfixion

Culdoplasty – Douglas pouch closing without douglassectomy

Utero sacral ligaments suture and mesh reperitonization

Restore normal anatomy rectum/vagina

Operating strategy

Fixation of the second mesh anteriorly bladder dissection just above the balloon of the

bladder catheter fixation of the mesh with 3 or 5 non absorbable

sutures, non transfixing no staples on vagina wall passage on the right side through broad ligament

(or bilateral passage)

Operating strategySacral colpopexy

1 or 2 non absorbable suture (staples) proper tension with help of vaginal retractor

++ posterior mesh = no tension

++ anterior mesh = tension to correct cystocele strong extracorporeal knot upper reperitonization

if uterus is left in place: avoid a peritoneum window between right broad ligament and posterior peritoneum

Operating strategy

Post operative careFoley catheter 1 or 2 days

Antibio prophylaxis

Prevention of phlebitis

Hospital stay 2 or 3 days

No heavy loads for 6 weeks

No sexual intercourse for 4 weeks

ResultsFew short term or long term studies

Follow-up Authors Year N 1 year 2 years

Nezhat 1994 15 100% Vancaillie 1995 42 90% Ross 1996 89 95% Gaston 1999 214 90% Mandron 2003 263 98% Bruyere 2002 76 96%

ResultsKouri, Cosson: Comparaison de la voie chirurgicale et coelioscopique, à propos de 218 cas

Group I (SCALI) 100 cases 1990-1995

Group II (laparoscopy) 118 cases1997-2000

CYSTOCELE 2 or 3

Repaired RECTOCELE:

Group I: 14 posterior perineum

Group II: 2nd laparoscopic sling – 7 cases

ResultsKouri, Cosson: Comparaison de la voie chirurgicale et coelioscopique, à propos de 218 cas

Results at 12 months GROUP I GROUP II Anatomic result 98 94 Per-op complications 2% 8% Post-op complications 8% 7% Hospital stay 8D 5D Re-intervention rate 2 cases 4 cases

ResultsOperative time

2 meshes Year N mn

Cosson 2002 83 292 180

Bruyere 2001 73 270 100

(164)

Mandron 2003 100 75

(45 115)

Giolitto 2004 170 80

(60 110)

ResultsCystocele results

cystocele degree 4 2 wait and see 1 case: second lower mesh proper tension with vaginal retractor

Year N 1 year results

Ross 1997 19 100%

Wattiez 1997 92%

Gaston 1999 214 94%

Mandron 2003 263 98%

Giolitto 2004 170 97%

ResultsRectocele results

few series with posterior rectal mesh open surgery (1 mesh) 33% recurrent rectocele

lower rectocele posterior mesh higher rectocele

Year N Results

Lyons 1997 20 80%

Ross 1997 19 84%

Gaston 1999 63 87%

Giolitto 2004 170 95%

ResultsOperative complications

Open conversion

Cosson 6/83 Technical difficulties

Nezhat 1/15 Sacral artery injury

Giolitto 2/170 Technical difficulties

previous abdominal surgery

obesity

ResultsBladder injuries

about 1% Giolitto: 4 cases/170

- suture vicryl-monocryl 3-0

- bladder catheter 2-3 days

- antibioprophylaxis 5 days

- negative preoperative urine culture

- no contraindication to fix the mesh

ResultsPost-operative complications

brochial plexus injury

Bruyere 1 case post operative bowel obstruction

Gaston 4 cases

1 hernia trocar

3 inadequate reperitonizations (1 ileal resection)

Giolitto 3 cases

3 inadequate reperitonizations (1 ileal resection)

ResultsPost-operative complications

Spondylitis

Giolitto 0

Gaston 2 cases

1 case with post operative haematoma

1 case with hysterectomy

Butreau 1 case

Diagnostic

- at 2 to 6 months

- removal of the meshes

ResultsLong term complications

Second vagina mesh displacement

Gaston 9 cases/429

posterior mesh but fixation with continuous sutures (vagina ischemia)

prevention fixation with 3 or 5 separate nonabsorbable

sutures on posterior vagina Post operative constipation

Mandron 70 cases - 2004

1 month 6 months

Previous posterior fixation 90% 13%

New posterior fixation with broad mesh

15% 10%

ConclusionLaparoscopy

advantage of the treatment by laparotomy low morbidity such as the vaginal route reproducibility of the technique time: around 90 minutes further studies required