Goals of sacrocopalpexy are to suspend the vaginal cuff or cervix up to the sacrum. Tensioning of this mesh is variable for each patient and depending on healing and shrinkage can lead to mesh contracture. We present three patients who underwent surgery for persistent peri-umbilical pain following sacrocopalpexy performed at outside institutions. On our initial exam, all three patients exhibited pain on deep palpation directly over the sacral promontory. Our first patient is a 62-year-old with five years of worsening peri-umbilical pain after an uncomplicated robotic-assisted supracervical hysterectomy and sacrocopalpexy. Her pain was described as a tugging sensation deep below her umbilicus and radiating to her rectum. Upon exam, significant tension was palpated at the vaginal apex without evidence of mesh exposure. Dynamic pelvic MRI was notable for a fixed vaginal angle toward the sacral promontory with minimal movement and descent with strain. You can also see an enteroseal. Decision was made to proceed to the operating room for mesh revision. Upon entry into the abdomen, a very tight mesh bridge was noted with significant small bowel adhesions. Lysis of adhesions was carefully performed until the mesh was fully visualized. The mesh was then completely transected in the midline to release tension. A suture was then threaded through the proximal mesh. New mesh was then inserted to create a bridge. Sacrocorporeal knots were tied to secure the mesh proximally. Here you can see significant improvement in vaginal apex mobility. The distal end of the new mesh was sutured to the vaginal portion of the previously cut mesh. This resulted in significant lengthening between the sacrum and the vaginal apex. The cuff was palpated to be significantly relieved of tension without recurrence of a prolapse. The mesh was then retroperitonealized. Prior to placement of the mesh bridge, a Moskowitz enteroseal repair was performed in a purse string fashion. She underwent a repeat dynamic pelvic MRI nine months post-operatively. Compared to the pre-op MRI on the left, you can see significant improvement in vaginal apical mobility, shown by the green arrows. Following the surgery, her peri-umbilical pain improved by 60%. Similarly, the second patient is a 45-year-old with a nine-month history of deep peri-umbilical pain and dyspareunia. Eleven months prior, she underwent a total laparoscopic hysterectomy and sacrocopal pexy. Immediately following the surgery, she experienced umbilical discomfort with a tenting sensation. On the patient's dynamic MRI, the vaginal apex appeared to be fixed and immobile. After six months of minimal improvement with pelvic floor physical therapy and pelvic floor Botox injections, she was taken to the operating room for surgical correction. Intraoperatively, the blue mesh was visualized through the peritoneum to be on significant tension and densely adhered to the right pelvic sidewall. The mesh was carefully dissected and divided to release tension. Following mesh division, a gap can be seen between the cut ends of the mesh. Due to the patient's significant scarring and pain, a decision was made to not insert a mesh bridge. The patient recovered well with immediate resolution of her umbilical discomfort and no recurrent prolapse. Our third patient is a 39-year-old with severe pelvic pain and tugging, peri-umbilical discomfort for four years following an open abdominal sacroculpopexy. Here you can see significant tethering at the vaginal apex. Her pain was persistent despite pelvic floor physical therapy and pelvic floor Botox injections. Intraoperatively, the mesh was visualized to be very taut. The mesh was carefully dissected and then completely transected in the midline. Significant improvement in vaginal apical mobility was visualized laparoscopically. The peritoneum was then opened. A new mesh bridge was then attached to the free edges of the mesh in a similar fashion to our first case. The mesh was then re-peritonealized. Here on the pre-op and post-op MRIs, the green lines represent apical descent with valsalva. You can see there is significantly more vaginal apical mobility on the post-op MRI on the right compared to the pre-op MRI on the left. The patient recovered well with resolution of a peri-umbilical tugging sensation without recurrent prolapse. This is a unique series of three patients who all presented with unusual yet similar complaints of persistent peri-umbilical pain following sacroculpopexy. Given the intraoperative findings and improvement in symptoms after mesh revision, this pain was attributed to excessive mesh tension. To our knowledge, this is the first reported case series describing these unique findings of peri-umbilical pain caused by excessive mesh tensioning after sacroculpopexy. When performing sacroculpopexies, careful consideration should be taken to prevent over-tensioning of mesh. Mesh contracture should be included on the differential when evaluating patients with vaginal apical pain with minimal descent after sacroculpopexy. Additionally, sacral promontory pain may be suggestive of overly-tensioned sacroculpopexy mesh. If conservative measures fail, surgical management can be considered to release and bridge the mesh to potentially improve symptoms.

sacrocopalpexy surgery

peri-umbilical pain

mesh revision surgery

vaginal apex mobility

excessive mesh tension