PFD Week 2016-Laparoscopic Sacrocolpopexy for "Gap Failure" after Anterior and Posterior Mesh Repairs

Video Transcription

Laparoscopic sacrocopalpexy has been shown to be an effective surgical procedure for the treatment of post-hysterectomy vaginal vault prolapse. We present an unusual case  of recurrent vaginal vault prolapse after a vaginal mesh prolapse procedure. The patient  is a 52-year-old multiparous woman who presented with a recurrent prolapse two years after an  anterior and posterior mesh repair. On examination, the anterior and posterior vaginal walls were  well supported with palpable mesh. Her vaginal apex descended to plus two with Valsalva maneuver  and was atrophic and thin on palpation. The patient was counseled and elected to undergo  a laparoscopic sacrocopalpexy for the treatment of recurrent prolapse. When anterior and posterior  meshes place vaginally, there is the potential for development of gap failures between the graft segments, which corresponds to the location of the vaginal apex.  Laparoscopic evaluation confirmed the presence of mesh anteriorly, although there was a fairly  large segment of anterior vaginal wall that was not covered with mesh. Similarly, mesh could be  visualized and palpated posteriorly and did not provide coverage to the length of the posterior  vaginal wall. The anatomic structures of the presacral space were identified, paying special  attention to the right ureter, the common iliac arteries, and the left common iliac vein, which  the classic waterbed sign. The bladder was backfilled with 200 cc's of dye stain fluid, and dissection was performed to create a peritoneal flap and expose the mesh.  Similarly, this was performed posteriorly, gaining access to the rectovaginal space and exposing the mesh. An incision is made in the peritoneum over the sacral promontory,  and dissection is continued until the anterior longitudinal ligament of the sacrum is exposed.  The peritoneal incision is extended inferiorly, staying lateral to the rectum and medial to the right uterus sacral ligament, and therefore away from the right ureter.

Video Summary

This video discusses a case of recurrent vaginal vault prolapse after a vaginal mesh repair procedure. The patient, a 52-year-old woman, experienced prolapse two years after the initial repair. Examination showed well-supported anterior and posterior vaginal walls with palpable mesh, but the apex of the vagina was descended and atrophic. The patient chose to undergo laparoscopic sacrocopalpexy for treatment. Laparoscopic evaluation revealed that the mesh did not fully cover the anterior and posterior vaginal walls, which may have contributed to the recurrent prolapse. The video also mentions the identification of anatomical structures and the surgical steps involved in the procedure. No specific credits are mentioned in the transcript.

Asset Subtitle

Peter L. Rosenblatt, MD, FACOG

Keywords

recurrent vaginal vault prolapse

vaginal mesh repair

laparoscopic sacrocopalpexy

mesh coverage

surgical steps