Total Laparoscopic Cerclage Sacrohysteropexy with Tunneling
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Total Laparoscopic Cerclage Sacrohysteropexy with Tunneling |
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Video From Boston Urogynecology Associates |
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This Video Uploaded At 18-08-2020 19:28:36 |
Video Discription |
INTRODUCTION: There has been a growing interest in uterine preservation at the time of prolapse surgery. The laparoscopic cerclage sacrohysteropexy is a previously described surgical technique that originally involved attachment of mesh using a vaginal Shirodkar cerclage technique. We present a novel and totally laparoscopic approach to this procedure which minimizes the need for laparoscopic suturing.
OBJECTIVE: To present a novel approach to total cerclage sacrohysteropexy
METHODS: The original laparoscopic cerclage sacrohysteropexy was described in 2016 and involved standard laparoscopic dissection for the sacrohysteropexy combined with transvaginal mesh attachment. In our approach to a total laparoscopic cerclage sacrohysteropexy, we begin with basic laparoscopic entry using four 5mm trocars. The peritoneum overlying the sacral promontory is incised and the anterior longitudinal ligament is identified. A disposable 5mm roticulating dissector is used, which allows us to follow the curve of the pelvic sidewall staying medial to the ureter and lateral to the rectosigmoid, ending in the posterior cul-de-sac. Next bilateral incisions are made on the posterior peritoneum at the level of the cervico-uterine junction to facilitate placement of the cerclage mesh. Anteriorly, an incision is made between the uterus and bladder so the cerclage mesh can lie down around the cervix with the bladder safely out of the way. The lateral edge of the cervix is identified and the space between the cervix and uterine vessels is developed bilaterally to ensure safe placement of the cerclage mesh through the paracervical tissue at the cervico-uterine junction. A 3 mm blunt instrument is then placed through the paracervical tissue, medial to the uterine vessels. The mesh is then brought posterior to anterior on the left side and then anterior to posterior on the contralateral side. The leading end of the mesh is placed through a loop at trailing end, thereby completing the cerclage. At this point the roticulating instrument is placed back through the retroperitoneal tunnel and the mesh tail is brought through the tunnel to the sacral promontory. After determining appropriate tensioning, the mesh is sutured to the anterior longitudinal ligament with permanent suture. A delayed absorbable suture is then used to close the bladder flap peritoneum. Similarly, a figure of eight suture with delayed absorbable suture is used to close the peritoneum over the sacral promontory.
RESULTS: Total laparoscopic cerclage sacrohysteropexy is an efficient, simple and time-saving surgical option for women with apical prolapse who desire uterine preservation. Our novel technique using a roticulating dissector minimizes the need for laparoscopic suturing. To date we have performed over 45 procedures in this manner and have experienced no perioperative complications. Early anatomic results have been excellent.
CONCLUSIONS: In conclusion, the total laparoscopic cerclage sacrohysteropexy with retroperitoneal tunneling is a significant improvement over the original technique that minimizes the need for laparoscopic suturing. We have found this to be an effective surgical treatment for patients with predominantly apical prolapse and who prefer uterine preservation. |
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