The abdominal sacral hysterocopalpexy involves elevating the vagina and uterus using polypropylene mesh secured to the sacrum. Open abdominal sacral hysteropexy has favorable data with cure rates ranging from 91 to 100 percent, with complication rates similar to sacral copalpexy. Studies supporting this procedure also describe improvements in quality of life and sexual function. Descriptions of the laparoscopic hysteropexy have been limited to utero sacral ligament plication and suspensions and suture sacral hysteropexies. In our experience, the use of mesh only on the posterior vagina and cervix has led to a persistent anterior apical defect. In order to correct the defect and improve anatomic outcomes, we have modified the procedure by using two strips of mesh, one on the anterior vagina and one on the posterior vagina. The objectives of this video are to describe clinical considerations for uterine sparing prolapse repairs and demonstrate the technique for dual mesh laparoscopic sacral hysterocopalpexy. It is important to select patients carefully for uterine sparing prolapse repairs. Women with prolapse who also have disease specific to the uterus, such as postmenopausal bleeding, endometrial hyperplasia, or cervical dysplasia, should have a concurrent hysterectomy as part of their surgery. Women at high risk for future gynecologic cancers, such as those with a strong positive family history or high risk HPV exposure to the cervix, may consider having a hysterectomy as well. Additionally, one must pay close attention to cervical length during the physical exam. Patients with cervical elongation are at higher risk for recurrence and may require concomitant partial trachelectomy. Finally, although encouraging pregnancy outcomes have been reported after vaginal sacrospinous hysteropexy, the use of permanent mesh on the anterior and posterior vagina and uterus in sacral hysterocopalpexy may complicate future pregnancies. Given the implications of uterine sparing procedures, the risks and benefits of hysterectomy versus no hysterectomy have to be carefully reviewed by the physician and patient. The rectovaginal dissection is performed as in a sacral copalpexy using one EEA sizer in the posterior vaginal fornix and a second EEA sizer in the rectum. The dissection is performed over three centimeters of the most cephalad portion of the vagina. The vascovaginal dissection is performed as in a sacral copalpexy with the EEA sizer in the anterior vaginal fornix. The dissection is performed over three to four centimeters of the most cephalad portion of the vagina. The three-way Foley catheter may be used to retrograde fill the bladder to identify the margin between the bladder and cervix. Using the laparoscopic scissors, the peritoneum is elevated and an incision is made into the peritoneum overlying the promontory. The presacral fat is cleared off to expose the anterior longitudinal ligament at the S1-S2 level. Unique to this procedure and not routinely performed in a traditional sacral copalpexy, a window is then created in the broad ligaments bilaterally. This defect in the ligament allows each arm of the anterior polypropylene mesh to be introduced in an anterior to posterior direction as will be demonstrated later in this video. An area of the broad ligament approximately one centimeter inferior to the round ligament and one to two centimeters lateral of the uterine edge free of any vessels is located. Using a Maryland grasper, a blunt dissection is performed by directing the instrument in a posterior to anterior direction. The tips of the grasper are spread to create a defect approximately one centimeter in diameter. A similar window is created on the contralateral side. The peritoneum is further extended over the two windows of the broad ligaments. The anterior vaginal mesh is cut in the shape of a square with an arm on each side. Each side of the square measures four to five centimeters. Each arm measures one centimeter by ten to eleven centimeters. The measurements should be tailored to the width of the patient's cervix and vagina. The anterior vaginal mesh is introduced and attached to the vagina with the arms facing cephalad. We prefer to place two interrupted 2-0 PDS stitches attaching the mesh to the vagina on the more distal portion of the anterior vaginal dissection. Next, two interrupted 2-0 PROLINE or 2-0 ETHABON stitches are placed into the mesh and cervix on the most proximal portion of the dissection for a total of four stitches. A third row of two interrupted stitches of 2-0 PROLINE may be placed but is not necessary. The posterior vaginal mesh measures four by fifteen centimeters. The posterior vaginal mesh strip is introduced and attached to the posterior vagina and cervix. It is often easier to first place a stitch and then introduce the mesh with the two suture ends woven through. A total of four to six interrupted stitches of 2-0 PROLINE or ETHABON are placed to secure the mesh. Each arm of the anterior mesh is directed through the broad ligament window. The Maryland Grasper is introduced through the window as was done during the dissection. The edge of the mesh arm is grasped and pulled posteriorly through the window in the broad ligament. This illustration demonstrates an anterior view of the uterus with the anterior mesh attached and arms pulled through the broad ligaments. The anterior and posterior meshes are tensioned. A 2-0 PROLINE interrupted stitch is placed through the right arm of the anterior mesh, then through the posterior mesh, through the anterior longitudinal ligament, and then back through the posterior mesh and left anterior arm. Excess mesh is trimmed. A second stitch is placed in a similar fashion. The stitches are tied down. This illustration demonstrates a posterior view of the uterus with both anterior arms and posterior mesh attached to the promontory. The peritoneum is re-approximated over the anterior and posterior mesh using 2-0 VICRAL suture. The key points of this video are, understand the contraindications of uterine sparing procedures such as laparoscopic sacral hysterocopalpexy. Review the risks and benefits of the procedure thoroughly with the patient. The effects of the modified technique on future pregnancies are not known at present, and we do not recommend this procedure in patients desiring future fertility. We have performed the procedure with both conventional laparoscopy and robotic-assisted laparoscopy. The use of two strips of mesh has led to improved anatomical outcomes and resolution of anterior apical vaginal wall and uterine prolapse. In conclusion, the laparoscopic sacral hysterocopalpexy seems to be a safe procedure with acceptable results in women who desire uterine preservation.

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laparoscopic sacral hysterocopalpexy