Abdominal Sacral Colpopexy and Colpohysteropexy

Suspension of the vagina or vagina and uterus to the sacral promontory by means of an abdominal, laparoscopic, or robotic 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, I prefer this procedure to a vaginal repair when there is obvious failure of the compensatory support mechanisms of the pelvis, especially in the very young patient; when there is coexistent rectal prolapse that will require an abdominal approach ( Fig. 41.1 ); or when the vagina has been foreshortened as a result of previous repairs ( Fig. 41.2 ). Many different graft materials have been used for abdominal sacral colpopexy. Biologic materials include fascia lata, rectus fascia, dura mater, and porcine bladder. Synthetic materials have included polypropylene mesh, polyester fiber mesh, polytetrafluoroethylene mesh, Mersilene mesh, Silastic silicone rubber, and Marlex mesh, but currently the material of choice is polypropylene. Most surgeons prefer a Y-mesh that has specifically been marketed for sacral colpopexy ( Fig. 41.3 ). When there is a contraindication to synthetic mesh or the patient does not want permanent mesh to be used, my material of choice is MatriStem Pelvic Floor Matrix (ACell Inc; Columbia, Md.), which is derived from porcine bladder ( Fig. 41.4 ).

Technique for Open Abdominal Sacral Colpopexy with Graft Placement

The technique for open abdominal sacral colpopexy with graft placement is as follows:

1.
The patient should be placed in Allen stirrups ( Fig. 41.5 ) or in a frogleg position so that the surgeon has easy access to the vaginal area during the operation. A sponge stick or an end-to-end anastomosis (EEA) sizer ( Fig. 41.6 ) 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 total or supracervical 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 with an EEA sizer, the peritoneum over the vaginal apex is incised and the bladder dissected from the anterior vaginal wall. The peritoneum over the posterior vaginal wall is incised into the cul-de-sac, longitudinally along the back of the vaginal wall. The vaginal apex is then elevated bilaterally with clamps or stay sutures ( Figs. 41.7 to 41.9 ).
4.
As 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 I use involves placement of a series of delayed absorbable (usually 2-0 or 3-0 PDS) sutures, through the full fibromuscular thickness of the vagina but not through the vaginal epithelium ( Fig. 41.10 ). A synthetic graft (Y-mesh) ( Fig. 41.11 ) or grafts are then fixed to the anterior and posterior vaginal walls. Sutures are fed through the graft in pairs and tied. The graft should extend down the anterior vaginal wall and at least halfway down the length of the posterior vaginal wall ( Figs. 41.11 to 41.13 ). If two separate grafts are being used, they are separately attached to the anterior and posterior vaginal walls and then sutured together and fixed to the sacral promontory.
5.
A longitudinal incision is then made over the peritoneum of the sacral promontory. The landmarks for this incision should be the right ureter and medial edge of the sigmoid colon ( Fig. 41.14 ). Before any dissection, it is sometimes helpful to pass sutures through the edge of the peritoneum ( Fig. 41.15 ). Elevation of these sutures facilitates dissection in an appropriate plane. 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 ( Fig. 41.16 ). 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. 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. 41.17 and 41.18 ). These vessels should be completely avoided. Ligation or coagulation should never be performed in the hope of preventing vascular injuries, as these vessels will retract into bone and create bleeding that is 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 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 are 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. 41.18 and 41.19 ). 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 are then fed through the graft, paired, and tied ( Figs. 41.20 and 41.21 ). The appropriate amount of vaginal elevation should provide minimal tension and avoid undue traction on the vagina.
6.
If necessary, a Moschcowitz or Halban procedure can be performed to obliterate the lower cul-de-sac, or the peritoneum over the cul-de-sac may be excised. Whatever technique is used, ultimately the graft must be extraperitonealized; thus the edges of the openings from the vagina to the sacrum are closed with a running delayed absorbable suture (see Fig. 41.20 ).
7.
Cystoscopy should be performed to ensure ureteral patency and bladder integrity.
8.
When appropriate, retropubic urethropexy or paravaginal repair may be performed in conjunction with this procedure. In addition, posterior colporrhaphy and perineoplasty usually need to be performed to treat the remaining rectocele and perineal defect, as well as to decrease the size of the genital hiatus. A transvaginal midline repair of a cystocele may also be necessary.