Part 2: laparoscopic enterocele repair and vaginal vault suspension.
As in general hernia surgery, use of mesh prostheses should be considered for severe procidentia or recurrent prolapse.
Laparoscopic reconstruction of genital prolapse requires four basic steps:
* Restore the integrity of the fibromuscular vaginal tube by repairing the enterocele. Reattach the pubocervical fascia to the rectovaginal septum.
* Resuspend the apex of the vagina to the level of the ischial spine by using the proximal part of the uterosacral ligaments or longitudinal ligaments on or just below the promontory of the sacrum.
* Use retropubic paravaginal suspension to reattach the midvagina to the pelvic sidewalls. Reattach the fascia endopelvina to the arcus tendineus fascia of the pelvis. If the arcus tendineus fascia is partially or completely pulled off the pelvic sidewall, suspend the fascia endopelvina to the ipsilateral side of Cooper's ligament.
* Repair the rectocele and perform perineorrhaphy vaginally if necessary. Identify the rectovaginal septum and attach it to the medial fascia of the levator ani and reconstructed perineal body with permanent, nonabsorbable sutures. Close the vaginal epithelium with fine, delayed-absorbable suture.
Trocar Sites and Placement of Vaginal and Rectal Probes
Pelvic floor reconstruction involves repairing the defects of deep pelvic structures; therefore, it is crucial to have adequate exposure of the operative field, freedom of access, and the ability to place sutures from an optimal angle and direction during the procedure. For this reason. I use five punctures--a 10mm umbilical puncture and four 5-mm lower abdominal punctures--for my trocar placements. The lower trocars are placed lateral to the deep inferior epigastric vessels on each side, and the upper trocars are placed lateral to the rectus abdominis muscle at about the level of the umbilicus.
It is important to have a vaginal and rectal probe on hand during laparoscopic repair of enterocele and vaginal vault suspension. The snow-white-colored vaginal probe makes the laparoscopic identification of the enterocele sac and its margin much easier, and thus facilitates the resection of the sac and permits easier identification of the broken edges of both pubocervical and rectovaginal fascia.
Laparoscopic Enterocele Repair and Vaginal Vault Suspension
The patient is placed in a low dorsolithotomic position for laparoscopic surgery. A Foley 18 Fr. catheter with a 5-mL balloon is inserted into the bladder. After routine preparation and draping for laparoscopic surgery, all five trocars are inserted.
The abdominal and pelvic organs are carefully inspected using a 10-mm laparoscope through the umbilical trocar sleeve. The patient is then placed in a 15-to 20-degree Trendelenburg's position, and the bowels are pushed back to the upper abdomen--with the small bowels pressed firmly up to the right to remain out of the way--thus fully exposing the pelvis.
The vast majority of enteroceles are posterior and central, whereas anterior enteroceles are rare. Special care must be paid to the ureters in anterior enterocele repair, because they may pass over the enterocele sac before entering into the bladder.
Therefore, in any enterocele repair, the first step is to identify and dissect out both ureters. Ureters can be easily identified at the pelvic brim by pushing the infundibulopelvic ligament anteriorly and laterally. This simple maneuver tenses up the peritoneum overlying the ureter, permitting visualization of peristalsis of the ureter.
Open the peritoneum overlying the ureter at the level of the midpelvis with scissors and dissect almost to the bladder.
Insert a vaginal probe and adjust it to push the apex of the vagina toward the patient's head. The enterocele sac, which is stretched-out peritoneum and vaginal epithelium without intervening fascia, will appear as a translucent, thin membrane over the white vaginal probe. Identify the anterior border of the enterocele and use scissors to make a transverse incision on the pelvic peritoneum over the border of the enterocele.
Dissect the anterior peritoneum inferiorly toward the bladder so that the broken edge of pubocervical fascia, which appears thick over the vaginal epithelium, can be seen. The bladder may have to be dissected away from the broken edge of pubocervical fascia in larger enteroceles.
Insert the rectal probe and use it to press the rectum away from the vagina. With the vaginal probe in the vagina pushing the apex of the vagina anteriorly and superiorly toward the patient's head, open the peritoneum between the rectum and vagina transversely. Enter the rectovaginal space and dissect deeply and widely to permit visualization of the medial fascia of the levator ani muscles laterally on both sides. The inferior portion of the rectovaginal space should be dissected until the broken edge of the rectovaginal septum can be identified. In large enteroceles, this may be very close to the posterior introitus.
With good dissection of the rectovaginal space, the broken edge or the remnant of the rectovaginal septum can usually be visualized through the laparoscope. However, in large enteroceles, the surgeon may have to put his or her finger inside the vagina to palpate and mark the border of the rectovaginal septum.
For the repair of medium and large enteroceles, the enterocele sac must be excised. Suture the edges of the pubocervical fascia and the rectovaginal septum with a purse-string suture using 0-sized Vicryl or Dexon absorbable suture. Remove the vaginal probe and seal off the vagina with a surgical glove balloon (that is, a surgical glove filled with some air and tied off). Next, excise the enterocele sac.
Small enterocele sacs can be inverted into the vagina without excision before the purse-string suture is tied.
Reapproximate the broken edges of pubocervical fascia and rectovaginal septum anteriorly and posteriorly with two layers of permanent nonabsorbable sutures, restoring the integrity of the fibromuscular vaginal tube.
In a woman with normal anatomy, the apex of the vagina is at the level of the ischial spine. My preferred technique to restore the anatomy to this level is to suspend the vaginal vault using the proximal uterosacral ligaments. This approach restores the normal vaginal length and axis in the midline position, and--unlike sacrocolpopexy--it does not require the use of graft material. It is quick to perform and has a good long-term success rate.
To begin, insert the rectal probe and push the rectum to the right side of the pelvis, exposing the left pararectal space Under laparoscopic view, insert two fingers into the vagina and palpate the ischial spine on the left side. The suture will be placed deep into the proximal uterosacral ligament, approximately 2 cm medial and 1 cm cephalad to the ischial spine.
Using a permanent nonabsorbable suture and a large curved needle (CV-0 with THX-36-needled Gore-Tex suture is my favorite), place a double-looped stitch deep into the left proximal uterosacral ligament. This figure-of-eight suture must be tugged to ensure a good bite of the uterosacral ligament and to test its strength. (This suture is placed under direct visualization of the left ureter, which has been dissected out at the very beginning of the procedure.)
Next, suture the ligament to the left side of the vaginal apex, making sure to take a good bite, but avoiding suturing into the vaginal lumen. Perform the same procedure on the right side.
Tie the sutures with an extracorporal knot-tying technique, making sure there is no suture gap between the uterosacral ligament and the apex of the vagina.
Graft Material Considerations
In patients who have a large prolapse or who have failed previous repairs, it may be difficult or even impossible to identify the endopelvic fascia. In these patients, a synthetic mesh graft with permanent material, such as Prolene or Mersilene, may offer the best hope for a successful repair.
Graft rejection and infection are concerns, with incidence rates varying from lower than 5% to as high as 20%. In our practice, 10%-15% of patients require synthetic mesh grafts for their prolapse repairs. We use Prolene mesh graft exclusively, and so far we have had only one graft rejection/infection. Our results may be explained by the fact that we never enter the vaginal canal when we use mesh grafts, believing that if the synthetic foreign-body graft mesh is exposed to contaminated vaginal bacterial flora, then the mesh material and blood exudates from surgery would inevitably cultivate the eventual infection. If the vagina were entered accidentally during such a surgery, our recommendation would be to use a two-layer closure of the vagina and to irrigate the vagina copiously as soon as the vaginal defect is detected.
BY C.Y. LIU, M.D
Go to this Web site to view a video of Dr. Liu performing laparoscopic enterocele repair and vaginal vault suspension. High-speed Internet access is required.