In this video, we demonstrate our approach to excision of an infected myrceline mesh almost seven years after a laparoscopic sacral copalpexy for vaginal valve prolapse. Sacral copalpexy remains an effective surgical procedure for advanced and recurrent vaginal prolapse with over 40 years of clinical experience. Laparoscopic or robotic assisted sacral copalpexy has become increasingly popular in the past decade. In a review of sacral copalpexy by Nygaard et al., published exposure rates of various mesh types demonstrated higher rates for multifilament grafts such as PTFE, braided polyester, and Teflon compared to lighter weight type 1 monofilament polypropylene which has become the material of choice for prolapse and slings. The patient in this video is a 63 year old para 1 who had a vaginal hysterectomy with McCall Coldoplasty and AP repair in 2002. She developed recurrent vaginal valve prolapse and underwent a laparoscopic sacral copalpexy with myrceline mesh and a paravaginal repair and TBTO sling in 2005. She then represented in 2013 with a three-year history of vaginal spotting and was found on exam to have a small apical mesh exposure. She subsequently underwent a vaginal mesh excision. Approximately one centimeter of myrceline mesh was removed as well as a cortex suture. At her two and six week post-op visits she complained of a malodorous vaginal discharge though no further vaginal mesh exposure was observed. At seven weeks her discharge and bleeding increased despite treatment with metronidazole gel. A decision was made to perform an EUA and probable laparoscopic excision of the mesh due to the suspicion of a chronically infected myrceline mesh. Laparoscopic survey of the pelvis was performed and the location of the mesh from the vaginal apex to the sacrum was clearly identified. The course of the right and left ureters were also identified. Using endoshears and monopolar energy the peritoneum overlying the vaginal apex was opened and the bladder was dissected off the anterior vaginal wall. A releasing incision was made in the peritoneum just lateral to the mesh and medial to the right ureter and sharp dissection was used to allow lateral mobilization of the ureter away from the tail of the mesh. Blunt dissection using marylin dissecting forceps on the fluctuant tissue overlying the vaginal apex revealed a pus filled cavity which was evacuated and the content sent for culture. Further dissection into this cavity revealed the myrceline mesh which is notable for lack of any tissue in growth. With traction on the mesh sharp dissection was utilized for excision of the mesh from the vaginal epithelium. Gore-Tex sutures used for mesh attachment were also removed. The entire anterior arm of the mesh was excised along with the Gore-Tex sutures. The posterior mesh was also dissected off the posterior vaginal epithelium sharply. Gore-Tex sutures were also removed. A bowel retraction device was introduced into the left lower quadrant to help retract the rectosigmoid towards the left pelvic sidewall allowing for more visualization of the sacrum. The peritoneum overlying the sacral mesh extension was opened sharply towards the sacrum. The mesh was cut approximately two centimeters short of the point of attachment to the sacral promontory due to the risk of major vascular injury with attempting to dig out the mesh in this space. The excised mesh was removed through the five millimeter port site and copious irrigation of the pelvis was completed. Even after excision of most of the mercilane mesh there appeared to be substantial scar tissue elevating the vaginal apex. Excess fibrinous tissue was excised from the vaginal apex and evaluation for hemostasis was completed. As shown in this video, clinically infected multifilament mesh can successfully be managed using a minimally invasive approach.

infected myrceline mesh

recurrent vaginal valve prolapse

laparoscopic sacral copalpexy

mesh exposure

laparoscopic excision