This video describes the repair of an anterior sacral meningiocele at the time of abdominal sacrocopalpexy. Anterior sacral meningiocele is a rare anomaly characterized by herniation of a cerebral spinal fluid meningeal sac through a defect in the anterior aspect of the sacrum. Less than 300 cases have been reported in the literature. Anterior sacral meningiocele occurs sporadically or acquired in conditions associated with dural ectasia such as neurofibromatosis type 1 and Marfan syndrome. It is usually diagnosed in the second or third decade of life when it becomes symptomatic. It is more prevalent in women at a 4 to 1 ratio. Review of normal anatomy reveals the anterior longitudinal ligament running along the anterior sacrum. With an anterior sacral meningiocele, a focal erosion or hypogenesis of a portion of the sacrum allows a herniation to occur. Patients are often asymptomatic with the meningiocele incidentally found on imaging. If symptoms are present, they are commonly due to compression of pelvic organs with constipation being the most prevalent. Urinary retention, pelvic and back pain, and dysmenorrhea are also frequent complaints. Neurochips between the meningeal sac and the subarachnoid space may cause intermittent headaches, nausea, and vomiting. Nerve root compression may also create diminished rectal endotruser tone, numbness, and paresthesias in the sacral dermatomes and sciatica. The objective of this video is to demonstrate a rare surgical case of anterior sacral meningiocele repair at the time of abdominal sacrocopalpexy. Ms. S. F. is a 56-year-old G3-P3 with complaints of worsening vaginal bulge, pelvic pressure, and urinary urgency. On exam, she was found to have stage 3 uterovaginal prolapse. Urodynamic studies revealed normal capacity and compliance, interrupted flow pattern, detrusor activity, and elevated post-void residual. She reported a known history of sacral mass at the time of presentation, a CT of the abdomen and pelvis from 2002 revealed a 6 by 7 centimeter meningeal cyst. Prior to addressing her prolapse, she was referred back to neurosurgery for evaluation due to her increasing symptoms of pelvic pressure. A MRI was performed which revealed a multi-lobar anterior sacral meningiocele extending from the left lateral S1 to S2 foramen that had now grown to 18 centimeters in size without any solid components present. Management options were discussed for both pelvic organ prolapse and anterior sacral meningiocele. She declined conservative options for pelvic organ prolapse including pestering and copolysis. The treatment for anterior sacral meningiocele is surgical closure due to increasing risk over time of meningitis and continued growth of the meningiocele. Since compression of the meningiocele would provide adequate access for sacrocopalpexy, the decision was made to proceed with that repair. The surgery commences with placement of a lumbar drain at the L4 to L5 disc space. The patient is placed in lateral decubitus position. Placement in the correct space is confirmed with return of CSF fluid. The lumbar drain was then used to drain approximately 50 cc's of CSF fluid which allowed the meningiocele to slightly decompress. A clinical exam under anesthesia revealed stage 3 uterovaginal prolapse as shown here. A midline infra-umbilical incision was made from the umbilicus to just above the pubic bone as shown here and dissected down to the layer of the fascia. The fascia was then incised and the rectus muscles reflected laterally. The anterior peritoneal wall was carefully identified, opened, and incised. It was immediately evident the larger retroperitoneal anterior sacromeningocele was extending all the way to the anterior abdominal wall. Self-retaining retractors were then placed. The posterior peritoneum was identified and carefully excised over the meningiocele. A needle and then a small incision were used to drain a majority of the CSF fluid. Once the meningiocele was decompressed the posterior peritoneum was tagged at the edges and retracted for adequate exposure. The anterior sacromeningocele was slowly dissected with blunt and sharp dissection down to its origin which appeared to be coming from the S1 neural foramen. The anterior sacral promontory was gently exposed down to the anterior longitudinal ligament. The middle sacral vessels were visualized as shown here and then cauterized and transected. The meningiocele was then completely circumferentially dissected down to its base. The meningiocele was clamped at the base just above the neural foramen above the nerves. Fiber tape was then used to secure the base and tie the stack off. Multiple serial loops of fiber wire were then used to completely collapse the entire anterior sacral meningiocele. 4-0 Neuralon was then used to sew the distal opening of the meningiocele. Duracell, a synthetic hydrogel sealant, was used as an extra layer on the anterior sacral opening of the meningiocele. Attention was then turned to the supracerbical hysterectomy which was performed in the usual manner. After the hysterectomy, the bladder was carefully dissected off the cervix and vagina down to the level of the trigone. A total of 8 centimeters was appreciated of vaginal and cervical length. The Y-mesh was then cut on the anterior portion to 8 centimeters and anchored with OPDS quill suture in a running fashion. The posterior vaginal peritoneum was dissected down 7 centimeters and the Y-mesh attached in a similar manner. The sacral promontory was easily identified from the prior dissection by the neurosurgery team. Two 2-0 Gore-Tex sutures were placed in the anterior longitudinal ligament as shown here. With confirmation of good apical support, the mesh was attached to the promontory with Gore-Tex suture. The excess mesh was cut and removed. The large excess posterior peritoneal flaps were then overlaid over the mesh and the meningiocele repair and sutured closed. A portion of peritoneum was placed between the meningiocele remnant and the mesh as a barrier. Final inspection of the repair reveals the complete mesh and meningiocele remnant to be retroperitonealized. At the 6-month follow-up visit, patient SF denies vaginal bulge, pelvic pain, or pressure. She reports continued urinary urgency with elevated post-void residuals requiring intermittent straight catheterization. She was cleared from neurosurgery with no neurological complaints. Her POPQ revealed stage 2 vaginal support. In conclusion, this video describes a rare surgical case of anterior sacral meningiocele repair at the time of abdominal sacrocopalpexy. Thank you for the opportunity to present this surgical case.

surgical case

anterior sacral meningiocele repair

abdominal sacrocopalpexy

pelvic organ compression

constipation