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LAPAROSCOPIC MANAGEMENT OF GENITAL PROLAPSE:
LATERAL SUSPENSION WITH TWO MESHES
Service de Chirurgie Gynecologique (Pr. Dubuisson)
Clinique Universitaire Baudelocque,
C.H.U. Cochin Port-Royal,
123, Boulevard Port-Royal
75014 Paris, France.
Tel: 33-1-42-34-12-02.
Fax: 33-1-40-61-77-62
A large number of operative techniques to treat genital prolapse have
been described over the past forty years. The goal of these various treatments is to suspend the vaginal vault,
the uterus and the bladder correctly, and to repair the pelvic floor. Until a short while ago these treatments
took place by the vaginal route or by laparotomy. Thanks to the progress made recently with laparoscopy, it is
now possible to treat genital prolapse by operative laparoscopy. We report a new operative laparoscopic technique
that we have recently developed. It consists of colpo-uterine suspension achieved using two meshes fixed laterally
to the aponeurosis of the external oblique muscle above the iliac crest. The original aspect of this new approach
is that it enables complete treatment of genital prolapse using a laparoscopic approach without having to involve
the promontory or carry out very much peritonization.
Operative technique
The operation is always proceeded by bowel preparation. The actual operation
is carried out under general anesthesia with endotracheal intubation. The patient is placed in a lithotomy position
with the thighs spread moderately and bent up. After installing a bladder catheter, the uterus is cannulated using
a curette, which enables adequate exposure of the anterior and posterior vaginal walls. After insufflation and
transumbilical laparoscopy, three suprapubic ports are inserted under visual control. Two 5-mm trocars are inserted
3-4 cm above the iliac crest. The 10-12 mm midline trocars are inserted halfway between the umbilicus and the pubis.
Dissection of the vaginal walls.
Recto-vaginal
cleavage comes first and starts in the midline under the uterine insertion of the uterosacral ligaments. The bigger
the rectocele, the further down this cleavage continues. According to the anatomic pelvic floor defects, this dissection
is carried out laterally until the levator ani muscles. Vesico-vaginal cleavage is then carried out, and is taken
as low as required by the cystocele. To make these dissection procedures easier, the second assistant positioned
between the patient's legs uses a foam swab mounted on a long forceps inserted into the vagina.
Fixing of two strips of mesh to the utero-vaginal walls. We used two strips of Vicryl composite. The combination of polyglactine 910 and
polyester
(Ethicon) as been replaced by the manufacturer by a combination of polyglactine
910 and polypropylene since December 1998. The mesh is cut to obtain two long strips 3-4 cm wide. These are then
introduced rolled-up through the midline suprapubic trocar. The middle part of the rear strip is taken down then
fixed as low as possible on the posterior vaginal wall, then taken up to the posterior surface of the isthmus and
also to the levator ani muscles and the uterosacral ligaments. This
posterior mesh is fixed using several separate polyester
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sutures (Mersuture O, 26 mm curved needle, Ethicon). A Douglasorrhaphy is
then carried out starting 2-3 cm from the posterior insertion of the uterosacral ligaments. Closure is achieved
using successive sutures with polyester O suture material taking up the uterosacral ligaments and the serosa of
the rectum. If there is a very large rectocele and elytrocele, Douglasorrhaphy is carried out. The middle part
of the anterior strip is taken down in similar fashion and fixed to the anterior wall of the vagina under the cystocele
and to the uterine isthmus.
Lateral fixation of the two meshes to the aponeurosis of the external
oblique muscle above the iliac spine. This starts with the insertion
of the two strips along the sub peritoneal tunnel. A small cutaneous incision is made 2-3 cm above and to the rear
of the antero-superior iliac spin. The aponeurosis of the external oblique muscle is incised for 1 cm. Using this
approach a long curved forceps of the Kelly-type is inserted to create a subperitoneal tunnel reaching the abdominal
cavity, passing under the homolateral round ligament. This tunneling procedure is kept under visual control by
the laparoscope. On each side the end of each mesh is grasped the by Kelly-type forceps and taken outside at the
cutaneous incision above the iliac spine. In order to achieve this double transversal hammock, the end of the posterior
mesh first has to be taken through the homolateral broad ligament then under the round ligament, above the ureter
identified beforehand. The tension of these two hammocks is adjusted so that the vaginal vault is suspended at
the desired level. This adjustment takes place after exsufflating the CO2. The protruding ends of the meshes are
fixed symmetrically to the edges of the incision in the aponeurosis using polyester O suture.
Peritonization of the vesico-uterine fornix is carried out using Vicryl 2.0 and ensures that the meshes are completely buried.
Laparoscopic Burch technique may be associated if stress urinary incontinence is present. Pre and postoperative
antibiotic therapy is systematically prescribed. The patient is allowed to leave the hospital as soon as return
of bowel function and miction.
Our preliminary results confirm that our technique is feasible without major complications. The short term functional
and anatomic results are encouraging.
Although it is possible to associate a hysterectomy during the operation, laparoscopic lateral utero-vaginal suspension
is particularly indicated for women presenting predominantly cystocele and hysteroptosis, and who wish to keep
their uterus. Similarly to laparoscopic promontofixation, the limits for this operation are adhesions, a past history
of repeat laparotomy and pelvic peritonitis together with obesity. These counter indications are only relative
and depend on the surgeon's experience. These encouraging preliminary results need to be confirmed by more extensive
studies, both with respect to the number of patients and the duration of follow-up.
References:
Dubuisson JB, Capron C:
Laparoscopic iliac colpo-uterine suspension for treatment of genital prolapse using two meshes. A new operative
technique. J. Gynecol. Surg. 1998; 14: 153-159 |
