Sacrocopalpexy is considered the gold standard surgical intervention for apical pelvic organ prolapse. Reoperation rates for the laparoscopic approach have been reported to be 6.2%. However, the rate of mesh breakage specifically is unknown. On the other hand, the rate of vaginal mesh exposure is 2% on average. Risk factors include vaginotomy and concomitant total hysterectomy. We present a case of a 47-year-old para-6 with symptomatic anterior and apical vaginal prolapse following her hysterectomy in 2013. She underwent a robot-assisted laparoscopic sacrocopalpexy in 2015 with good 3-month post-operative results. However, in 2016, she developed symptomatic recurrence of her anterior prolapse but opted for expected management at that time. One year later, she requested surgical repair for her worsening prolapse. Examination showed that the vaginal cuff prolapsed to the hymen, suggesting a disconnection of the mesh from the sacrum. Additionally, a 3mm mesh exposure was noted at the vaginal apex. Therefore, she was scheduled for a robot-assisted laparoscopic revision of both the sacrocopalpexy and the mesh exposure. We will demonstrate the key steps of that procedure in the following footage. The sacral promontory was visualized and the previous sacrocopalpexy mesh was noted to be disconnected from it. The disconnected end of the mesh was identified and was confirmed to still be attached to the vagina. After the right ureter and iliac vessels were identified, the peritoneum overlying the sacral promontory was incised and dissection was made layer by layer towards the anterior longitudinal ligament. The proximal mesh stump was noted to still be attached to the ligament. The peritoneum was then incised caudally using a course that is halfway between the course of the right ureter and the sigmoid colon until it reached the disconnected arm of the mesh. The mesh exposure site was identified. Because of the apical vaginal mesh exposure, we decided to remove the apical portion of the mesh in order to repair the vagina. Polypropylene sutures were removed as needed. The surrounding mesh was then sharply dissected anteriorly, posteriorly and laterally with minimal use of cautery to prevent thermal injury and tissue necrosis. Careful, sharp and blunt dissection was utilized. Around 2 cm of mesh-free flap was created on each side around the vaginal defect. After dissection, polypropylene sutures were removed. The mesh exposure site was identified. The peritoneum was then incised caudally using a course that is halfway between the proximal mesh stump and the sigmoid colon until it reached the disconnected arm of the mesh. The peritoneum was then sharply dissected anteriorly, posteriorly and laterally with minimal use of cautery to prevent thermal injury and tissue necrosis. The peritoneum was then incised caudally using a course that is halfway between the proximal mesh stump and the sigmoid colon until it reached the disconnected arm of the mesh. The peritoneum was then sharply dissected anteriorly, posteriorly and laterally with minimal use of cautery to prevent thermal injury and tissue necrosis. The peritoneum was then sharply dissected anteriorly, posteriorly and laterally with minimal use of cautery to prevent thermal injury and tissue necrosis. The peritoneum was then sharply dissected anteriorly, posteriorly and laterally with The base of the mesh was excised. The vaginal defect was then repaired using multiple interrupted 2-O polyglactin sutures. A second imbricating layer was performed. During knot tying, the vaginal probe was partially withdrawn to prevent air knots. The bladder was backfilled to identify its margins. The vescovaginal space was partially dissected to create a peritoneal flap. The bladder was then re-drained. The rectovaginal space was also partially dissected to expose about a 2 cm portion of the previous posterior mesh. A new Y-shaped type 1 monofilament polypropylene mesh was opened and cut to measure 2 cm anteriorly and 3 cm posteriorly. The anterior arm was attached to the previous anterior mesh with interrupted sutures of 2-O polypropylene and care was taken not to suture over the vaginal repair. The posterior arm of the new mesh was attached to the previous posterior mesh in a similar fashion. Tension was adjusted on the mesh to reduce the prolapse. The base of the mesh was then sutured to the pre-existing mesh stump at the anterior longitudinal ligament at the level of the sacral promontory with three interrupted 2-O polypropylene sutures. The second and third sutures incorporated two plies of the mesh for stronger support. Excess mesh was trimmed. The third suture was applied to the anterior vertebral ligament cephalad to the stump of the mesh. The mesh was retroperitonealized with a running 3-O absorbable suture. Four months after surgery, the patient was asymptomatic and satisfied. On exam, there was good anterior and apical support and no evidence of recurrent mesh exposure. In summary, we suggest the following key points for a successful repair. For laparoscopic revision of mesh exposure, using sharp and blunt dissection techniques with judicious use of cautery may help prevent thermal damage. In addition, double-layer closure may promote better healing of the vaginal tissue. Furthermore, consideration can be made for a vascular flap between the new mesh and the vagina to prevent recurrence, although we did not incorporate one in this procedure. To decrease the risk of mesh rupture after sacral copalpexy, we recommend a two-ply folding of the base of the mesh at the sacral promontory. In addition, we suggest avoiding excessive instrumentation of the tension-bearing portion of the mesh to prevent weakening of the polypropylene filaments.

robot-assisted laparoscopic sacrocopalpexy

vaginal prolapse

mesh exposure

revision surgery

double-layer closure