We present a novel approach to sacroservicopexy that addresses the recognized difficulty in placing fixation sutures in the sacral promontory. The patient is a 42-year-old woman who presented with symptomatic stage 2 prolapse and urodynamic stress incontinence who requested surgical repair. This video demonstrates our technique for LSH with sacroservicopexy using a novel transcervical approach to sacral fixation. The procedure begins with identifying the ureters, which are seen peristalsing along the pelvic sidewall, as well as identifying the sacral promontory. The supracervical hysterectomy is performed in standard fashion using an advanced bipolar device. After desiccation of the uterine arteries bilaterally, a bipolar loop is introduced to amputate the uterine body from the cervix. Notice that the uterus is completely cyanotic, confirming successful bilateral occlusion of the vessels. The specimen is placed in the right upper quadrant, and transcervical coring is performed manually to remove the lining of the endocervical canal and to create an access port for the sacroservicopexy. A 12-millimeter cannula is then placed through the cervical defect. The ectocervix will be closed at the completion of the procedure with a vaginally placed purse-string suture. A T-lift device is used to aid in retraction of the bowel and improve our visualization of the sacrum without utilizing additional laparoscopic port sites. A tension is then turned to the sacral promontory where monopolar scissors are used to open up the peritoneum and the dissection is carried down to the cul-de-sac. The surgeon's two fingers are placed in the posterior vaginal fornix to delineate the rectovaginal plane. The cervix is then deflected posteriorly and the bladder is back-filled with a dye-stain solution, which can be helpful to identify the proper surgical plane. The bladder is further dissected off the anterior vaginal wall using both blunt and sharp dissection. A pre-formed Y-shaped piece of lightweight polypropylene mesh is inserted through the cervical cannula and is placed over the port using a slit that was cut in the upper posterior arm. The mesh is laid down flat both anteriorly and posteriorly. CV2 gortec sutures are introduced through the cervical port and placed anteriorly using a Cooke self-righting needle driver. Starting at the cervix and working more distally, a series of interrupted CV2 and CV3 gortec sutures are placed anteriorly using an extracorporeal knot tying technique. Needles are removed through the cervical port after each stitch. This allows us to keep our four laparoscopic port sites to a size of only 5 mm each. Excess mesh is then trimmed and removed from the abdomen. A similar procedure is performed along the posterior vagina. The most apical sutures are placed into the cervical stroma and continued distally along the posterior vaginal wall. Care is taken to leave space to perform the posterior colpotomy. Using a bipolar spatula, the colpotomy is performed over a vaginal probe. The specimen is then placed in the posterior cul-de-sac and removed vaginally using ring forceps. The colpotomy is then repaired vaginally using 2-O-Vicryl in a locked running fashion. The suture line is inspected laparoscopically to ensure hemostasis and closure. The tail of the mesh is then unrolled and appropriate tensioning is determined to provide adequate apical support. After the mesh is cut to the correct length, the Endo360 device is brought in through the cervical port and a 2-O-Proline suture is placed in the anterior longitudinal ligament of the sacrum. The Endo360 is a reusable suturing device with a normally shaped curved tapered needle for which a variety of sutures can be utilized. The individual tails of the suture are then brought up through the mesh and then out through the lateral laparoscopic ports. A second 2-O-Proline suture is introduced again through the cervical port and placed in the anterior longitudinal ligament. The Endo360 is able to rotate and articulate which allows for precise placement of each suture. Again, the tails of the suture are placed through the mesh and then out the lateral port. The sutures are then tied down using an extracorporeal knot tying technique. Finally, the peritoneum is closed over the mesh using barbed suture. The cervical cannula is removed and the purstring suture is tied vaginally. It has been demonstrated that many surgeons incorrectly place the sacral fixation stitches in the L5-S1 interdisc space which can lead to chronic complications from discitis. Transcervical suture placement with the Endo360 provides a more anatomically accurate, precise and reproducible suspension.

sacroservicopexy

transcervical approach

supracervical hysterectomy

polypropylene mesh

Endo360 device