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Laparoscopic And Minimally Invasive Procedures Continued
Laparoscopic Sacral Colpopexy
Sacral Colpopexy Fig: 0.1
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The abdominal sacral colpopexy is one of the most successful operations for vaginal vault prolapse with excellent results. It involves suturing a synthetic mesh that connects and supports the vagina to the sacrum (tailbone). This procedure is complex in its nature and requires great expertise for a favorable outcome. Drs. Miklos and Moore have been performing the laparoscopic sacral colpopexy in the same manner as an open procedure with the exception of using a laparoscope over the past 5 years. They have the largest series of laparoscopic sacralcolpopexies ever published in the world. They recently reported the results of almost 500 cases, completed over the past 3 years at international meetings in Russia, Mexico and the United States. This was one of the featured research papers presented also at the 2007 American Urogynecologic Society Meeting in Miami, Fl.(link to abstract here). Many physicians and academicians do not believe the laparoscopic sacral colpopexy can be performed in a safe and efficient manner. Drs Miklos and Moore can perform this procedure in less time with more sutures than the open sacral colpopexy. Drs Miklos and Moore do not believe in changing the technique of the operation but only the mode of surgical access into the abdomen. |
Advantages
By performing the sacral colpopexy laparoscopically, our physicians are able to reposition the vagina to its anatomic position in a minimally invasive manner. Most surgeons perform this procedure through a large incision thus contributing to a longer recovery time. Our laparoscopic approach also allows us to incorporate additional laparoscopic procedures if needed.
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Sacral Colpopexy Fig: 1 |
Sacral Colpopexy Fig: 2 |
Sacral Colpopexy Fig: 3 |
Drs Miklos & Moore can perform the laparoscopic sacral colpopexy ( Figure 2 & 3) in less time, less blood loss, smaller incisions and perform the surgery more precisely than by doing it through an open laparotomy (Figure 1). They are one of only a few centers in the country offering this procedure through the laparoscopic approach and are by far the most experienced in the country with the technique. Surgeons from all over the US and internationally have come to their center to learn their techniques.
Surgical Technique for Laparoscopic Sacral Colpopexy
After placing the four small incision sites noted above (Figure 2) and then placing the access ports (Figure 3), the bowel is mobilized out of the deep pelvis and the sacrum (tailbone) is identified (Figure 4). The peritoneum over the sacrum (tailbone) is elevated (Figure 5) and then incised (Figure 6).
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Figure 4 – Sacrum |
Figure5 - Peritoneum elevation |
Figure 6-Incision |
Figure 4 - Sacrum Figure 5 - Peritoneum elevation Figure 6 - Incision
A sponge stick is placed into the vagina to elevate the apex or vaginal vault into the surgical field (Figure 7).
Laparoscopic view of vaginal vault with probe in vagina elevating the apex up into the pelvis |
Figure 7a -- Vaginal vault (apex) |
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Figure 7b -- Vaginal vault (apex) : Probe holds vagina up from below |
The peritoneum covering the apex of the vagina is incised and the bladder is dissected away from the top of the vagina anteriorly and the rectum dissected away posteriorly.
A piece of mesh which is shaped like a Y (Figure 8) is then attached both to the posterior aspect of the vagina apex (Figure 9) and to the anterior vaginal apex (Figure 10).
Sacral Colpopexy Figure: 8 |
Figure 8 -- Y-shaped mesh |
Figure 9 - Anterior mesh attachment
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Figure 10 - Posterior mesh attachment
The long arm of the Y-mesh is then pulled up to the sacrum and subsequently attached. Figure 11 shows the placement of sutures into the sacrum, which will then be attached to the mesh. By attaching this suture to the mesh, the vagina is supported to the sacrum via a bridge of mesh between the vagina and sacrum. (Figure 12) The mesh is attached distally to the vagina (anterior & posterior) and proximally to the sacrum (Figure 14).
Figure 11 - Placing Suture In Sacrum
Figure 12 - Mesh From Vagina To Sacrum
The peritoneum, which was originally incised and opened at the beginning of the operation, is now closed over the mesh ( Figure 14). This part of the surgery does not add support to the surgery but is thought to decrease potential complications, like bowel obstruction and adhesions.
Fig 13 – Covering over the mesh with peritoneum
Figure 14- lateral view of mesh attached to the both anterior wall and posterior wall of vagina and then to the sacrum (tailbone)
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Results/Complications
Drs. Miklos and Moore have an excellent success rate with the laparoscopic sacral colpopexy. Their rates, recently reported at the American Urogynecology Society Annual Mtg (Miami, 2007) are equivalent to an extensive review of the open abdominal sacral colpopexy procedures at most major universities. The cure rate of the laparoscopic sacral colpopexy is approximately 90-96%.
More Information
In Dr Miklos and Moore’s recent study of 463 patients undergoing Laparoscopic Sacralcolpopexy, their cure rate at one year is 98%, with minimal complications noted.
Some of the complications that can occur during Sacral Colpopexy include:
Sacral Colpopexy Complications
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Mesh Infection |
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Mesh Erosion |
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Bleeding |
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Pain with intercourse |
Dr. Miklos and Moore have a <1% intra-operative complication rate during this procedure due to their vast experience in advanced pelvic reconstructive surgery. They view the laparoscopic approach only as a mode of surgical access. The laparoscope does not modify their technique in performing the procedure. Risks such as mesh infection or rejection are very rare with the newer mesh used, which is a macroporous soft polypropylene mesh (Type I mesh). In their recent series of almost 500 cases, only one mesh had to be removed secondary to infection (cuff infection at time of hysterectomy) and one was removed secondary to a question of an inflammatory reaction. No other infections attributed to the mesh was seen.
The most common risk of the use of mesh at the top of the vagina, is mesh extrusion through the vaginal skin, which is typically a minor complication, but one that does need a procedure to excise the exposed mesh and repair the skin where it came through. This risk exists whether the procedure is completed through an open incision or the laparoscope, however in their recent study, Dr Miklos and Moore reported an overall extrusion rate of only 1.2%, which is lower than most other reports in the literature. They also showed that women with hysterectomy were no more likely to suffer a mesh complication (such as extrusion, infection, pain, bowel symptoms) than patients that already previously had a hysterectomy. Please click here to view the ABSTRACT from the AUGS 2007 meeting, or the PAPER submitted for publication reporting on their results.
Atlanta Urogynecology Associates Experience
Drs. Miklos and Moore have performed the laparoscopic sacral colpopexy procedure over the past 5 years with a success rate comparable to the abdominal sacral colpopexy (large incision). They have also seen a much lower complication rate by performing it laparoscopically instead of through a large incision. By maintaining the same principles of this original proven surgery, Drs. Miklos and Moore can offer their patients the most advanced mode of entry to a highly successful surgery that corrects vaginal vault prolapse. They have the largest series of laparoscopic sacralcolpopexies ever reported in the world to date and have reported on their results and have taught the procedure all over the world. Physicians and surgeons from institutions such as Dartmouth, Univ. of Louisville, George Washington Univ, Cleveland Clinic, Harvard, Johns Hopkins, Brown Univ, Univ Cincinatti in the US as well as surgeons from all over the world including Australia, Chile, France, Korea, Japan, Sweden, S. Africa, Greece, and others have come to their center in the US to learn their techniques (testimonials). They also get invited on to typically 3 to 5 centers throughout the world to travel to the center to do live surgery to demonstrate their technique to teach other surgeons. Last year alone they operated in Portugal, Russia, Chile, Greece, Turkey, S.Africa and Dubai.
Some centers now are offering Robotic Assisted Laparoscopic Sacralcolpopexies. The robot is used to perform the same procedure Dr Miklos and Moore are performing and is used by surgeons that otherwise are not able to do the surgery laparoscopically. It allows some surgeons the ability to do a surgery laparoscopically, when otherwise they could not it this way because of the technical difficulty of the procedure and the advanced skills necessary. Dr Miklos and Moore do not use the robot, because it offers them no advantage and actually is a disadvantage because of the time and cost involved it takes to do the procedures robotically. Dr Miklos and Moore typically complete the procedure in less than 45 minutes and in most series using the robot, it takes 4-6 hours, therefore adding risk of increased operating time to the procedure (ie longer anesthesia, longer time of the patient being in the operating room). It does however offer some surgeons the advantage of doing the procedure laparoscopically instead of through a large incision and if it can be done in a reasonable time frame, this is an advantage to the patient (ie instead of having a large incision in the abdomen).
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