PFD Week 2016-Laparoscopic Enterocele Repair: Closure of Enterocele And Uterosacral Ligament Suspension After Total Vaginal Mesh Placement

Video Transcription

Laparoscopic Repair of Enterocel and Apical Defect Following a Total Vaginal Mesh Placement This is a 67-year-old Gravita II Paratube who presented in March of 2008  complaining of a vaginal bulge. She had undergone in the past an abdominal hysterectomy, bilateral salpinga oophorectomy due to fibroids, and a cholecystectomy and appendectomy.  On POPQ exam, she had evidence of anterior vaginal wall prolapse with points AA and BA at plus 3. In May of 2008, she underwent an anterior reconstruction  with graft augmentation using a polypropylene mesh, enterocel repair, a trans-obturator sling, and cystoscopy. In September, she presented complaining of another vaginal bulge.  Her exam revealed a posterior vaginal wall prolapse with points AP and BP at plus 2. She became extremely bothered by the prolapse in October  and underwent a posterior reconstruction with graft augmentation with polypropylene mesh, bilateral sacrospinous ligament fixation, and peroneoplasty in December.  A year later, she presented complaining of another bulge. Her POPQ exam revealed able descent with points C at plus 5. A 4D ultrasound was performed.  With Valsalva, an enterocel is seen protruding through the introitus.  In January, she underwent a laparoscopic enterocel closure and bilateral utero sacral ligament suspension.  Lighted ureteral stents and a vaginal stent were placed. Manipulation reveals the enterocel.  Using a blunt grasper, tactile sensation is used to help identify the posterior mesh.  Seen here are the posterior mesh arms.  The bladder flap is created using monopolar energy and blunt dissection.  Once the bladder flap is taken down, the anterior mesh is identified.  Posteriorly, the peritoneum is taken down to identify the rectovaginal septum and the posterior mesh.  An EEA sizer is placed in the rectum to delineate the rectovaginal space and placement of the posterior mesh.  Initially, imbrication of the enterocel was attempted. However, due to the long vagina and excessive amount of vaginal mucosa,  it was decided to excise an area of vaginal mucosa at the apex.  For more UN videos visit www.un.org

Video Summary

In this video, a 67-year-old woman with a history of abdominal surgeries presents with vaginal bulges caused by prolapses in her anterior and posterior vaginal walls. She undergoes multiple procedures including reconstruction, graft augmentation, sling placement, cystoscopy, ligament fixation, and peroneoplasty. However, a year later, she experiences another bulge caused by an enterocel. In January, she undergoes laparoscopic enterocel closure and utero sacral ligament suspension. The procedure involves identifying the mesh, creating a bladder flap, identifying the rectovaginal septum, and placing the posterior mesh. Due to excessive vaginal mucosa, a portion of it is excised at the apex of the enterocel. No credits are granted in the video. For more videos, visit www.un.org.

Asset Subtitle

Renee Bassaly, MD

Keywords

vaginal bulges

prolapses

abdominal surgeries

enterocel

mesh placement