Uterine prolapse is a prevalent condition among women and is often associated with anterior and posterior wall defects. Lauder and colleagues have demonstrated that simulated apical support using one blade of a speculum in patients with advanced prolapse corrects over half of anterior wall and almost a third of posterior wall defects. Therefore, providing preferential support to the cervix could effectively treat a large percentage of women with advanced uterovaginal prolapse. Laparoscopic or robotic sacrohystoropexy remains a challenging procedure for many pelvic surgeons, requiring a significant amount of skill and experience, especially with endoscopic suturing and knot tying. With uterine preservation, some centers have described placing windows in the broad ligament to place mesh both anteriorly and posteriorly before attaching the sacral mesh extension to the sacrum. In this video, a novel technique for performing mesh sacrohystoropexy is demonstrated, which may not only simplify the procedure by eliminating most endoscopic suturing and knot tying, but may also significantly reduce the operating time without compromising the long-term efficacy of the operation. This procedure, called the cerclage sacrohystoropexy, leverages the extensive clinical experience with cervical cerclage used in the obstetrical treatment of incompetent cervix. To review the Charadkar cerclage technique, a synthetic tape or mesh is placed circumferentially around the cervical isthmus after dissecting the bladder and rectum off the cervix. After tying or suturing the ends of the cerclage together, the vaginal epithelium is closed over the tape so that no tape is exposed vaginally. The cerclage sacrocystoropexy is begun laparoscopically. After identification of the ureters and sacral anatomy, the peritoneum over the sacral promontory is incised and dissection is performed to expose the anterior longitudinal ligament. The incision is then carried down along the right pelvic sidewall, lateral to the rectum and medial to the ureter. An incision is then made in the peritoneum between the vagina and the rectum and dissection is performed in the rectovaginal space. At this point, the surgery continues vaginally. With tenaculums placed on the anterior and posterior cervix, simulated cervical support demonstrates resolution of this patient's anterior wall prolapse. After injecting local anesthesia with a hemostatic agent, an incision is made from 10 o'clock to 2 o'clock at the anterior cervical vaginal junction and dissection of the bladder off the cervix is performed. Similarly, another incision is made between 8 o'clock and 4 o'clock and the rectum is advanced off the posterior cervix. Entry into the posterior cul-de-sac can easily be performed, given that the peritoneum was already open laparoscopically. In this case, the I-stop mesh, which is usually used as a midurethral sling, is being utilized and the connectors are cut off each end. Using a reusable Emmett needle, the cervix is perforated from posterior to anterior on the right side at the level of the isthmus, staying medial to the uterine vessels. The sling is then pulled back through the cervix. The same procedure is performed on the left side, making sure the tape lays flat anteriorly on the cervix. The two ends of the mesh are then sutured together on the medial edges in order to create a wider mesh segment for attachment to the sacrum. The anterior vaginal incision is closed with a running, absorbable suture. At this point, the sacral extension is placed into the cul-de-sac. A 12-millimeter balloon tip trocar was then inserted through the cul-de-sac to gain access to the pelvic cavity. After determining the proper tension on the sacral extension, the excess mesh was trimmed away. Using the Endo360 suturing device, a stitch of braided polyester is placed through the anterior longitudinal ligament of the sacrum. Using a transvaginal approach has two advantages. First, the angle of approach allows proper placement at the level of S1. And secondly, we can keep all of our laparoscopic port sites at 5 millimeters in size. The two ends of the permanent suture are then threaded up through the sacral mesh extension. A second suture is placed in a similar manner. Before tying down these sutures, the cannula in the cul-de-sac is removed and the posterior vaginal incision is closed with a running, absorbable suture. The sacral sutures are then tied down to elevate the uterus back into a normal position. The peritoneum is then closed over the mesh with barbed suture. Cerclage sacrohistoropexy may be a viable option for providing apical support while reducing technical challenges associated with endoscopic suturing and knot tying. The final needle is removed through the suprapubic incision. Final examination after the procedure reveals a well-supported cervix with no apparent anterior or posterior wall defects.

cerclage sacrohystoropexy

uterine prolapse treatment

synthetic tape or mesh

laparoscopic and vaginal surgery

I-stop mesh