Laparoscopic sacrocolpopexy is a well-established technique to treat apical vaginal prolapse. De novo micturition disorders, pelvic pain, and defecation disorders have been reported and may be due to intraoperative compromise of the superior hypogastric plexus. The video demonstrates our technique for nerve-sparing laparoscopic sacrocolpopexy. The patient is a 62-year-old woman with symptomatic stage III posthysterectomy vaginal vault prolapse. Key steps of the procedure are opening the peritoneum at the level of the promontory, identification of the fibers of the superior hypogastric plexus, deep anterior and posterior dissection with attachment of the mesh to the vagina, displacement of the nerve fibers to the left side during suturing of the mesh to the longitudinal ligament, and complete peritonealization. This technique of the identification and protection of relevant nerve structures appears to be reproducible and can be considered by surgeons who perform laparoscopic sacrocolpopexy.
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Problem: de novo pelvic organ dysfunction
Laparoscopic sacrocolpopexy for apical vaginal prolapse has demonstrated excellent anatomic and functional outcomes. However, de novo pelvic organ dysfunction has been reported after laparoscopic sacrocolpopexy and may be due to compromise of fibers of the superior hypogastric plexus.
The superior hypogastric plexus is located at the level of the aortic bifurcation and contains mainly sympathetic fibers from the sympathetic trunk. The superior plexus then branches out to form the right and left inferior hypogastric plexuses, which pick up parasympathetic fibers from the splanchnic and inferior mesenteric nerves. At laparoscopic sacrocolpopexy particularly, dissection of the presacral space can compromise fibers of the superior hypogastric plexus and contribute to postoperative problems such as incomplete voiding, defecatory dysfunction, pain, and sensory problems.
The Video shows the identification and preservation of the superior hypogastric plexus during the presacral dissection at laparoscopic sacrocolpopexy. The key step is visualization and gentle displacement and preservation of fibers of the superior hypogastric plexus at the level of the promontory and right pelvic sidewall.
The Video also shows the procedure in a 62-year-old woman with complete posthysterectomy vaginal vault prolapse (cystocele III° and rectocele II° according to the International Continence Society/Interational Urogynecology Association–classification).
The dissection begins at the vaginal apex, which is demonstrated with a vaginal retractor. The peritoneum is incised, and the bladder is dissected off the anterior vaginal wall.
A rectal probe is inserted for better access to the rectovaginal space. The rectovaginal space is dissected to detach the rectum from the posterior vaginal wall down to the level of the ventrolateral part of the levator ani muscle. To avoid rectal injury, care is taken not to detach the perirectal fatty tissue from the rectum.
The presacral peritoneum is opened on the right side of the midline, and the fibers of the hypogastric plexus are identified under the peritoneum. The nerve fibers cross to the right pelvic wall. They are pushed dorsally away from the site of the later incision of the peritoneum. The segment of the longitudinal ligament is then exposed for later mesh fixation, and the nerves are displaced gently to the left side to avoid impairment ( Figure 1 ).
For better exposure of the surgical field, the sigmoid is suspended to the left lateral pelvic wall with a transabdominal suture.
The peritoneum is now incised superficially and parallel to the sigmoid to create the retroperitoneal space for the mesh. The superficial incision respects and protects the superior fibers of the hypogastric plexus.
An anterior and a posterior piece of macroporous polypropylene mesh (Parietene; Covidien, Dublin, Ireland) are fashioned to the required shape. The posterior mesh is introduced first and attached distally to the levator muscles on either side of the rectum. More proximally, the posterior mesh is sutured to the vaginal apex with nonabsorbable 2-0 sutures (Ethibond Excel; Ethicon Inc, Somerville, NJ). Next, the anterior mesh is introduced and attached to the anterior vagina right at the level of the internal urethral meatus. Apically the anterior mesh is attached with 2 tension-free stitches through the vagina. Now the 2 mesh pieces are attached to the sacrum with 2 stitches through the anterior longitudinal ligament of the promontory (L5). During this step, the nerve fibres are gently displaced to the left, thus avoiding injury ( Figures 2 and 3 ). The entire mesh is then covered by closure of the peritoneum in the midline ( Figure 4 ).