Uterine prolapse is a common condition encountered in female pelvic medicine. Traditionally, hysterectomy was recommended as part of the treatment protocol prior to valve suspension. More recently, however, uterine preservation has been sought by many women and therefore treatment options such as laparoscopic uterine suspension with mesh, also known as laparoscopic mesh hysterepexy, has been described. In this surgical video, we demonstrate our technique of laparoscopic mesh sacrohysterepexy in a patient requesting uterine conservation with a history of multiple myomas. A uterine morcellator is placed to help facilitate movement of the uterus throughout the procedure. Pedunculated fibroids are then removed first and then any intramural fibroids are injected with a pertussin solution to help minimize bleeding. The intramural fibroids are removed utilizing a combination of electrical energy as well as ultrasonic energy. The capsule of the fibroid is excised, the fibroids grasped, and removed via standard laparoscopic myomectomy techniques. The uterus is debulked via myomectomy down to a size that makes it amenable for laparoscopic suspension. The defects from the myomectomies are then closed utilizing standard laparoscopic suturing techniques and or barbed suture. We find that a combination of utilizing a barbed suture as well as a laparoscopic suture of running monocryl or similar suture closes the defects in an efficient manner as well as leads to excellent hemostasis. Care is taken to ensure a multi-layer closure, especially on any area that mesh may be in contact with. Once the defects have been closed, a piece of type 1 polypropylene mesh is added into the pelvis. It has been previously cut to size according to the anatomy of the uterus. Permanent sutures are utilized to attach the mesh to the body of the uterus starting at the level of the cervix and then working our way up to the lower uterine segment and the mid-portion of the body of the uterus. If indicated by the patient's anatomy, the mesh can be extended down the posterior vaginal wall as well by opening up the rectovaginal space, extending the mesh down into the rectovaginal space and attaching it to the posterior vaginal wall via permanent sutures. In this particular patient, she did not have a rectocele or an intercele and therefore it was not indicated. The mesh is continued to be attached to the posterior portion of the uterus, taking care not to suture too deeply into the uterus as to avoid the suture being placed into the myometrium. In areas that previous fibroids have been removed and there's an incision in the uterus, this is especially important. Once the mesh has been adequately attached to the posterior portion of the uterus, the presacral ligament is then identified. The peritoneum overlying the sacrum and the sacral promontory is isolated and opened. Again, a combination of electrical and ultrasonic energy may be utilized to safely open up the presacral space. The peritoneum does not have to be open or extended too far deeply into the pelvis, however just enough to be able to retroperitonealize the portion of the mesh that will be exposed in the area. The presacral ligament is then cleaned off and dissected to an avascular portion. The uterine manipulator in the uterus is then utilized to elevate the uterus up into its normal anatomic position. Care is taken to ensure that the uterus is elevated up high enough, however that there is not too much tension or that the uterus is over-elevated. Once the proper height and tension have been identified, a suture of 2-O-Ethabond is then placed through the presacral ligament and the mesh to attach the mesh into place. Dark scissors are then utilized to cut off the excess suture and then the excess mesh is also excised. Again, we check the elevation of the uterus and if it feels as if it's in proper position, a second suture is placed through the mesh and through the presacral ligament and tied into position. This suture is also cut and the position of the uterus is checked both from above and from below. The mesh is then retroperitonealized utilizing a suture of 2-O-Monocryl in a running per-string type fashion. We feel that retroperitonealizing the mesh helps minimize risk of bowel-related complications following the surgery. The suture is then tied down ensuring complete covering over the mesh with the peritoneum and then cut. The final adjustment and position of the uterus is then checked from both below and above. The fibroids that were removed are then removed from the abdomen via standard morcellation techniques. This patient had excellent anatomic outcomes and is more than a year out from surgery with no complications to date. Laparoscopic mesh sacrohystrophexy is a technique that can be completed at time of concurrent laparoscopic myomectomy in select patients by experienced surgeons. Patients should also be aware and consented for all risks of mesh-related complications.

laparoscopic mesh sacrohysterepexy procedure

uterus preservation

fibroid removal

mesh support

laparoscopic myomectomy