The success of any laparoscopic reconstruction begins with a thorough understanding of pelvic anatomy. Site-specific repairs of all endopelvic fascial defects as described by Colin Richardson were addressed during the repair of this stage 3 vaginal ball prolapse. The initial dissection opens the vesicle vaginal space exposing the pubic cervical fascia separating it from the bladder. The anterocele sac is then visualized using a vaginal probe. This is followed by the rectovaginal space being dissected open beginning with the cul-de-sac peritoneum and dissecting down identifying the fascia overlying the iliococcygeus muscles bilaterally. Once this is dissected we're then able to identify the rectovaginal septum and identify any breaks in the fascial layer. Interrupted stitches of 2-0-ethabond are then placed in through the fascia overlying the iliococcygeus muscle and into the rectovaginal septum thus giving the site-specific reconstruction of the rectocele. This is accomplished with serial bites on either side closing any defects. The 2-0-ethabond is a permanent suture material which will not absorb. Extracorporeal knot techniques have been used. Once we've established the reconstruction of the rectocele we then identify the ureters and start our ureterolysis and separation of the uterus sacral ligaments from the ureter. The identification of the uterus sacral ligaments are readily seen and visualized. They run from the level of the ischial spine back to the level of the sacral area of 2, 3, and 4. The identification is obvious in this picture. These are accomplished bilaterally followed by interrupted stitches through the uterus sacral ligament and the superior aspect of the rectovaginal septum and then attached interruptedly to the ipsilateral sides. There is no crossing over the midline closing the cul-de-sac as in other procedures. This is purely an anatomical reconstruction as you can see the rectovaginal septum in its entirety. The uterus sacral ligament is then grasped. The pubocervical fascia is also attached followed by reattachment to the rectovaginal septum thus attaching the pubocervical fascia back to the rectovaginal septum closing the enterocele sac. This repairs both the enterocele as well as transverse cystoceles. The vaginal probe is then introduced and identification of further fascial defects are accomplished. We then are able to identify the pubocervical fascia once again. Stitches are placed through the pubocervical fascia and back down to the rectovaginal septum noting that there is no crossing over the midline. The cul-de-sac is completely open and there is no obstruction to the rectus sigmoid. The attachment is back out to the uterus sacral ligament allowing for safe closure of the enterocele sac re-approximating the endopelvic fascial layers. The pubocervical fascia again is identified to still be in separation from the rectovaginal septum and therefore we interrupt the layer and re-approximate using again 2-0-ethypon. The uterus sacral ligament fixation is safe, simple, anatomic and effective for both relief of symptoms and for the re-establishment of urogenital function.

laparoscopic reconstruction

vaginal ball prolapse

endopelvic fascial defects

rectovaginal septum

urogenital function