Abdominal Sacral Colpopexy

Mickey M. Karram

Suspension of the vagina to the sacral promontory by means of an abdominal approach has been shown to be an effective treatment for uterovaginal prolapse and vaginal vault prolapse. Although the exact indications for abdominal sacral colpopexy are controversial, the author prefers it to a vaginal repair when there is obvious failure of the compensatory support mechanisms of the pelvis, especially in the very young patient (Fig. 43–1), or when the vagina has been foreshortened as a result of previous repairs (Fig. 43–2). Many different graft materials have been used for abdominal sacral colpopexy. Natural materials include fascia lata, rectus fascia, and dura mater. Synthetic materials have included polypropylene mesh, polyester fiber mesh, polytetrafluoroethylene mesh, Mersilene mesh, Silastic silicone rubber, and Marlex mesh. Although homologous tissue in the form of cadaveric fascia lata and other xenografts have also been utilized for this operation (Fig. 43–3), at the present time the material of choice is polypropylene. The technique for abdominal sacral colpopexy with graft placement is as follows:

1. The patient should be placed in Allen stirrups or in a frogleg position so that the surgeon has easy access to the vaginal area during the operation. A sponge stick or an EEA (end-to-end anastomosis) sizer (Fig. 43–4) can be placed in the vagina for manipulation of the apex if desired. A Foley catheter with a large (30-mL) balloon is placed in the bladder for drainage. Prophylactic perioperative antibiotics are generally used during this procedure.

2. A laparotomy is performed through a low transverse or midline incision, and the small bowel is packed into the upper abdomen. The sigmoid colon is packed, as much as possible, into the left pelvis. The ureters are identified bilaterally. If the uterus is present, a hysterectomy should be performed and the vaginal cuff closed. The depth of the cul-de-sac and the length of the vagina when completely elevated are estimated.

3. While the vagina is elevated cephalad using an EES sizer, the peritoneum over the vaginal apex is incised and the bladder dissected from the anterior vaginal wall (Figs. 43–5 and 43–6). The peritoneum over the posterior vaginal wall is incised into the cul-de-sac, longitudinally along the back of the vaginal wall (see Fig. 43–5). The vaginal apex then is elevated bilaterally with clamps or stay sutures.

4. As was previously mentioned, many different graft materials have been used, and many different techniques for fixation of the graft to the vagina have been described. The technique we use involves placement of a series of nonabsorbable sutures (usually 0) transversely in the posterior vaginal wall 1 to 2 cm apart (Fig. 43–7). All sutures are placed through the full fibromuscular thickness of the vagina but not in the vaginal epithelium. Biologic or synthetic grafts are prepared as in Figures 43–3 and 43–8. Sutures then are fed through the graft in pairs and tied (Fig. 43–9). The graft should extend at least halfway down the length of the posterior vaginal wall. The author prefers to attach a second piece of mesh or fascia to the upper part of the anterior vaginal wall (Fig. 43–10). This piece of fascia then is sewn to the posterior piece of fascia, which will be attached to the sacrum (see Fig. 43–10), or both pieces are taken back to the sacrum.

5. A longitudinal incision then is made over the peritoneum of the sacral promontory. The landmarks for this incision should be the right ureter and the medial edge of the sigmoid colon (Fig. 43–11). Very gentle dissection of the areolar tissue underneath the peritoneum is performed, usually in a blunt fashion, with a suction tip or a swab mounted on a curved forceps. The surgeon should be careful to palpate the aortic bifurcation and the common and internal iliac vessels and to mobilize the sigmoid colon to the left and the right ureter to the right, so that these structures can be avoided. The left common iliac vein is medial to the left common iliac artery and is particularly vulnerable to damage during this procedure. Very gentle dissection is performed down onto the sacral promontory to allow identification of the longitudinal ligament of the sacrum. The middle sacral vessels should also be easily visualized (Figs. 43–12 and 43–13). These vessels should be completely avoided. Ligation or cauterization should never be performed in the hope of preventing vascular injuries, as these vessels will retract into bone and create bleeding that is very difficult to control. If bleeding is encountered in this area, pressure should be applied on the bleeding vessels with a sponge stick. If this approach is unsuccessful, consideration can be given to the use of bone wax or the placement of sterile thumbtacks. The bony sacral promontory and the anterior longitudinal ligaments are directly visualized for approximately 4 cm with the use of blunt and sharp dissection through the subperitoneal fat. As dissection is carried caudad, special care should be taken to avoid the delicate plexus of presacral veins that is often present. With a stiff but small curved tapered needle, two to four 0 nonabsorbable sutures are placed through the anterior sacral longitudinal ligament over the sacral promontory (see Figs. 43–12 and 43–14). As few as one or two sutures can be placed, depending on the vasculature and exposure of the area. The graft should be trimmed to the appropriate length. The sutures then are fed through the graft and are paired and tied (Figs. 43–15 and 43–16). The appropriate amount of vaginal elevation should provide minimal tension and avoid undue traction on the vagina.