Laparoscopic Ventral rectopexy/Posterior colporraphy/vaginal sacrocolpopexy
- one 5mm, two 12mm disposable trocars
- One 5mm fenestrated De’Bakey grasping forceps
- 5mm Harmonic scalpel
- Two 5mm needle holder
- 5mm Protacker
- 15 x 4 cm prolene mesh (tapering to 1cm)
- 1/0 Ethibond sutures (12cm length)
- D&C set/Sprackman if there is a uterus present.
Use gravity as much as possible ie steep headdown tilt and always use a 30 degree scope. Site the laparoscope through the umbilicus with 5mm and 12mm ports on the right.
Mobilise the sigmoid and rectum from the pelvis (reducing the prolapse). Notice the deep pouch of Douglas. The uterus is elevated using a Sprakman retractor.
Incise the peritoneum overlying the sacral promentry and continue inferiorly on the right hand side overlying the edge of the mesorectum. Dont divide the lateral ligaments or mobilise the mesorectum. Watch out for the pelvic nerves. It is easy to catch them in thin patients.
Continue the peritoneal incision (J extension) between rectum and posterior vaginal fornix. We usually go behind the pouch of Douglas. Leave a perirectal collar to provide counter-traction & enable proper peritonisation of the mesh. Douglassectomy is unnecessary. It is something to retract on and pull up the rectum or vagina.
Use the harmonic scalpel or blunt dissection to separate the vaginal/rectal septum (alternate between pulling-up on vagina/rectum). Go as far down the recto-vaginal septum as possible. Turn the laparoscope on the camera 360 degrees so that it looks forward. Remember to use gravity as much as possible. Elevate ad antivert the uterus using either a Sprackman or an extended velsellum intrauterine retractory. Ask a friendly gynaecologist to show you how.
Deliniate the vagina in post hysterectomy women using an Amielle vaginal dilator.
First fix the mesh to the front of the rectum (0 Ethidond x 4) - below and above the peritoneal reflection. Then fix the mesh to the posterior vagina and posterior vaginal fornix. Remember, it is easier to throw a double loop if the needle (not the suture) is held in the left-hand needle holder. In large prolapses envolving vagina and rectum, fix the mesh to the reduced vagina first followed by the rectum to the mesh (see below). Use 0 Ethibond x 3 with a furter two sutures placed between mesh and the posterior vaginal fornix or vault. Use 3 sutures through the tectum (place these below and above the peritoneal reflection.
A very large, heavy fibroid uterus may render hysterectomy necessary. However, in most case it is best to keep the uterus.
If there is an enteroceal or cystocoele, bi-valve and split the mesh suturing it to the mobilised front of the vagina/back of bladder. Never staple to the vaginal wall. Be very careful not to make a hole in the bladder. If you do, close with 00 PDS.
Secure the mesh to the promentry with 4 helical tacks (Protacker). Watch out for the vein and nerves.
Close the peritoneum over the mesh using a running suture (0 Ethibond).
Whilst we have performed an additional Birch colposuspension as necessary, we believe that a TVT sling at a latter date is probably a better option