| Sacral
Colpopexy
The information provided by Advanced
Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes
only. As each woman is unique, do not rely on this information for diagnosis and
treatment. We cannot guarantee the accuracy of the content and advise that you see a
qualified Health Care Professional for individual needs and care.
The sacral colpopexy is a surgical procedure that involves
attaching one end of a synthetic mesh to the top of the vagina and the other end to the
sacral promontory (upper part of the tail bone or lower part of the spine). The procedure
is one of the best ways to treat vaginal vault prolapse. With vaginal vault
prolapse, the structures that are attached to the vagina and hold it in place have torn
loose to varying degrees. This problem with pelvic support looks somewhat like grabbing
the toe of a sock from the inside and turning the sock partially, or completely, inside
out. Frequently, an enterocele (hernia at the top of the vagina) is present along
with the vaginal vault prolapse. A hernia is caused by a defect or hole in a strong,
canvas-like tissue called fascia. The mesh used with the sacral colpopexy is an effective
way to repair the defect in the tissue of the top of the vagina (enterocele). Several
other types of defects in pelvic support may also be present and should be corrected at
the same surgery.
Laparotomy vs. Laparoscopy
Very few gynecologists perform sacral colpopexy at laparotomy, and
even fewer at laparoscopy. The main concern many physicians have with this particular
surgical procedure is the many vital structures immediately surrounding, and in, the small
area of the sacral promontory. Within an area 2-3 inches square are located major blood
vessels, the ureter, and intestine. With training, experience, and meticulous surgical
technique, the risk of complication is small. In order to safely perform laparoscopic
sacral colpopexy, the surgeon must have extensive experience performing difficult cases at
laproscopy, must know the laparoscopic anatomy, and must be skilled at laparoscopic
suturing. The major advantage of performing the sacral colpopexy at laparoscopy is a
significant reduction in post operative recovery time and pain – because it is done
through small incisions rather than a large incision required at laparotomy.
The likelihood of success of the laparoscopic sacral
colpopexy is 80-90%.
Some of the complications that can occur include:
- Erosion of the mesh
- Infection of the mesh
- Bleeding at the time of surgery.
The procedure
Sacral colpopexy may be performed at laparotomy through a large
abdominal incision or at laparoscopy using several small incisions. Sacral colpopexy is
performed under general anesthesia in the operating room. If performed at laparoscopy, an
incision is made in the bottom of the belly button to introduce the laparoscope (see Laparoscopy
in Surgical Procedures). Another small incision is made just above the pubic
hair line in the midline and another just below the belly button several inches the right
and lateral to the midline. The last small incision is made on the left side of the
abdomen, again several inches lateral to the midline and just below the level of the belly
button. This last incision is where the instrument to do the laparoscopic suturing is
inserted.
Image 01 – The arrow points to the top of the vagina
where the enterocele (hernia) is located. A catheter with a balloon on the end can be seen
through the wall of the bladder above arrow.
Image 02 – An instrument in the vagina pushes the hernia
sack into the abdomen so the top of the vagina can be seen.
Image 03 – During the procedure, a piece of synthetic
"y"-shaped mesh is sutured to the upper vagina. One arm of the "y" is
attached to the anterior wall of the vagina and the other arm to the posterior wall of the
vagina. Since the bladder is attached to the anterior wall of the vagina and the rectum
next to the posterior wall of the vagina, these structures are dissected free before
placement of the mesh. In this image, the bladder that is attached to the anterior vaginal
wall has been dissected back to allow attachment of one arm of the y-shaped mesh. The
arrow is pointing to the anterior vaginal wall, and the instrument is holding the edge of
the bladder in the upper part of the picture.
Image 04 – This image is somewhat confusing. The
instrument in the vagina has been angled anteriorly to gain access to the area between the
vagina and rectum. The arrow is on the top of the vagina, and the rectum has been
dissected free from the posterior wall of the vagina.
Image 05 – The sacral promontory is indicated with the
middle arrow. The upper arrow points to the right ureter and the lower arrow to the right
common iliac artery. The sacral promontory is the lower part of the spine where the upper
end of the mesh is attached.
Image 06 – The tissue over the sacral promontory has
been opened and cleaned to allow attachment of the mesh.
Image 07 – The lower arrow identifies the sacral
promontory and the upper arrow the top of the vagina. An incision has been made along the
right pelvic sidewall (right side of the lower abdominal cavity for placement of the mesh.
Image 08 – The mesh has been sewn to the vagina and a
suture is being cut.
Image 09 – The mesh is being attached to the sacral
promontory with a stainless steel tack called a "Q-ring."
Image 10 – The mesh is seen in place extending from the sacral
promontory to the upper portion of the vagina.
Image 11 – To bury the mesh behind the peritoneum (a thin
SeranÔ wrap-like tissue that covers the inside of the abdominal cavity), the edges of the
peritoneum are being sutured together.
Image12 – The procedure has been completed, and the intestine
is seen in its normal position in the abdomen.
Image13 – A cystoscopy is performed to make sure the bladder is
normal and the ureters functioning. The arrow points to a ureteral orifice where blue dye
is seen. Cystoscopy is a procedure using a small telescope-like instrument to see the
inside of the bladder. The ureters are the tubes that connect the kidneys to the bladder.
The ureteral orifice is the opening of the ureter into the bladder.
Image14 – An irrigation instrument is seen coming in
through a lower port.
A final look in the abdominal cavity confirms there is no bleeding.
This procedure took approximately two hours, and the patient went home later that same
day.
E. Daniel Biggerstaff III, M.D.
July 24, 2004 |
