Our video is of a combined laparoscopic sacro-culpo-perineopexy and rectopexy. Our patient is a 56-year-old female who presented with complaints of vaginal bulge and pressure with defecatory dysfunction and chronic constipation. Her defecography showed a rectal intussusception, and her POPQ preoperatively showed significant prolapse. Past surgical history is significant for uterus sacral suspension. As you can see, the etheban sutures were still in place. During the procedure, we utilized a bowel retractor called the T-Lift, which comes with a needle trocar, approximately 2 millimeters. That is placed through the epiploic fat of the bowel. The T-shaped retractor is deployed from the trocar and then tensioned against the abdominal wall externally. As you can see, the sacrum and the ureters are now well visualized. Our dissection begins at the sacral promontory. Utilizing the harmonic scalpel, we're able to dissect through the peritoneum. Using a push and spread technique, separate the fat from the peritoneum and move our way caudally to the uterus sacral ligament, which is transected. We'll continue our dissection into the cul-de-sac. We'll further dissect through the uterus sacrals and the remnants from the uterus sacral suspension. At this point now, we'll be working on the rectus sigmoid to free it up. First, we'll dissect underneath it into the avascular plane above the sacrum. Here you can see we've dissected caudally to the coccyx, and we'll continue moving caudal until we reach the pararectal space, paying careful attention to the venous plexus that reside here. We'll continue to free up the rectus sigmoid from the right side, making our way to the left. Once completely free, we'll turn our attention to the left uterus sacral, where we'll transect it and dissect into the pararectal space on the left side. We'll continue to use a push-and-spread technique, as well as cautery with our harmonic scalpel. Now that our rectus sigmoid is free on the right side and inferior, we'll move on to a hysterectomy, which is performed in a supra-cervical manner in a usual fashion. At this point, we'll then add another T-lift retractor to move our rectus sigmoid to the right side and begin our dissection on the left. To completely mobilize the rectus sigmoid, we'll begin our dissection on the left side, medial to the uterus sacral ligament, to avoid the ureter. We'll continue to use a push-and-spread technique until we've reached sacrum inferiorly. We'll then come underneath the rectus sigmoid to connect our dissection plane from the right and from inferior to the rectus sigmoid. Now that we've come across from the right side to the left side, complete mobilization of the rectus sigmoid will be achieved. With our dissection complete, we can now identify the sacral promontory and tack the paracolic tissue with a bone tacker in order to straighten out the rectus sigmoid and correct the patient's interception. Here we can see the sacral promontory clearly and place our tack. After that, we're able to lay down a polypropylene mesh cut in a 4x8cm configuration and we're laying it below the rectus sigmoid with no attachment. Here you can see the tacking of the paracolic tissue on the right side, thus completing our repair of the interception. Now we've introduced a type 1 polypropylene Y-mesh into our cavity. We're placing it over our valvetrase retractor and securing it anteriorly. Here we're utilizing a 2-0 proline quill suture, allowing us to run the suture without having to tie any knots. We're paying careful attention to lay our mesh down flat without any folds or bunching. Once we've completely run the suture, we pull it tight and cut the end short so it'll retract back into the tissue. At this point, we're tucking away the tail of the Y-mesh and focusing on the posterior aspect of the cervix. Now we've made an incision vaginally and we're dissecting from the posterior vagina and perineal body into the peritoneal cavity where we pass the posterior arm of our Y-mesh to secure it to the perineal body externally. We use 2-0 PDS, a total of three stitches in the perineal body to secure it in place and make sure that it's laying flat and none of it is externalized. Once secured, we'll then close the vagina with a 4-0 monocryl, thus resealing the vagina and we'll be able to refill our abdominal cavity, recreate our pneumoperitoneum, as well as cover all the mesh in the vagina. Next we'll tack our sacral tail of the Y-mesh, thus tensioning our vagina in its proper anatomic position. And finally we'll re-peritonealize to completely cover our mesh. Postoperatively, the Y-mesh will be closed. The patient followed it for 5 months. She was sexually active and did not report dyspareunia. Her bowel symptoms were improved and her POPQ postoperatively showed no recurrence of prolapse. Thank you.

laparoscopic sacro-culpo-perineopexy

rectopexy procedure

vaginal bulge

defecatory dysfunction

chronic constipation