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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:
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. 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 (lower arrow) to the upper portion of the vagina (upper arrow).
Image 11 – To bury the mesh behind the peritoneum (a thin Seran® 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 opening 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.
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.