In this video, we will present a total laparoscopic cerclage hystereopexy. The original cerclage sacrohystereopexy involves standard laparoscopic dissection for the sacrohystereopexy, combined with transvaginal mesh attachment using a Charade-Carr cerclage technique. Based on the laparoscopic technique of cerclage placement for management of incompetent cervix, we modified our surgical technique and developed a novel approach to the cerclage sacrohystereopexy. This patient was a 64-year-old with a history of a prior anterior and posterior repair with mesh in a midurethral sling nine years earlier, who presented with recurrent prolapse and mixed incontinence. On exam, she had a stage II uterine prolapse and a tight posterior midvaginal mesh band with acute pain on palpation. Urodynamics confirmed stress incontinence. After performing a bilateral salpingia oophorectomy, we placed a T-lift device in the left lower quadrant to retract the rectosigmoid bowel to the left lateral side by placing the T-lift needle carefully through several epiploica. The sacral promontory was identified and an incision was made on the overlying peritoneum using monopolar electrocautery. This dissection was then carried down the lateral sidewall to the posterior cul-de-sac with care taken to avoid the ureters laterally and the rectum medially. Next, the peritoneum was incised posteriorly at the cervico-uterine junction on both the right and left sides to facilitate future placement of the mesh. This step facilitates passage of the 3mm blunt grasping instrument that will be shown later on in the video. We then turned our attention to the tight midvaginal band that was the upper margin of her previous transvaginal mesh. With a finger in the vagina, the tight band of mesh was palpated and using sharp dissection, the mesh was transected in the midline without difficulty. This immediately resulted in resolution of the tight horizontal mesh band. We again turned our attention to the sacral promontory where additional layers of the fibroadipose tissue were dissected off the anterior longitudinal ligament. The middle sacral vessels were desiccated given their prominence and location in this case although this may not be necessary in all procedures. We then turned our attention anteriorly. After identification of the cervico-uterine junction, an incision was made in the peritoneum between the bladder and the uterus to facilitate development of a bladder flap. Prior to insertion into the abdomen, a loop was created at the distal end of the cerclage mesh using several interrupted permanent sutures. The lateral border of the cervix and the uterine vessels were identified. A 3mm blunt laparoscopic instrument was passed through the paracervical tissue medial to the uterine vessels and the mesh was pulled through from posterior to anterior on the left side. The majority of the mesh was then brought through the incision such that the incision was not visible. The mesh was then brought through the incision such that the distal loop on the cerclage mesh was left at the level of the internal cervical os on the posterior left side. The 3mm grasper was then used to bring the mesh from anterior to posterior on the contralateral side. Posterior to the cervix, the proximal end of the mesh was placed through the loop on the distal end of the mesh which completed the cerclage at the level of the internal cervical os. The mesh was noted to lie flat against the anterior cervix. Appropriate tensioning of the mesh was determined and CV2 Gore-Tex sutures were used to fix the mesh to the anterior longitudinal ligament at the level of S1 and the sutures were tied down using an extracorporeal knot tying technique. During suture tie-down, an assistant pushes cephalad on the lightweight uterine manipulator to take the suture out of the way. The suture is then pulled through from anterior to anterior on the left side. The mesh was noted to lie flat against the anterior longitudinal ligament at the level of S1 and an assistant pushes cephalad on the lightweight uterine manipulator to take tension off the sutures. The second Gore-Tex suture is placed through the ligament and then through the mesh. Absorbable barbed sutures were then used to close the peritoneum overlying the mesh as well as the bladder flap, although this can be done with a non-barbed suture at the surgeon's discretion. The total laparoscopic cerclage sacrohystoropexy is an efficient, simple and time-saving surgical option for women with apical prolapse who desire uterine preservation. While the original cerclage sacrohystoropexy has been limited to patients with apical descent to the level of the hymen, the total laparoscopic cerclage sacrohystoropexy can be performed regardless of the degree of apical descent. To date we have performed 8 procedures in this manner and have experienced no perioperative complications. Early anatomic results have been excellent to date. www.ottobock.com

surgical technique

total laparoscopic cerclage hystereopexy

prolapse management

women

uterine preservation