This video describes two cases of a small bowel obstruction following internal herniation through a peritoneal defect, a rare complication of laparoscopic sacrocopalpexy. Laparoscopic sacrocopalpexy, including both robotic and traditional laparoscopy, have advantages over abdominal sacrocopalpexy, including decreased blood loss, decreased postoperative pain, and shorter hospital stay. Disadvantages include longer operating time and often require advanced surgical techniques. GI complications are rare, however laparoscopic sacrocopalpexy has a 1% rate of small bowel obstruction in ileus compared to 5.9% for abdominal sacrocopalpexy. Comparing robotic and traditional laparoscopy, the GI complication rate is the same. While the GI complication rates of sacrocopalpexy are low for both techniques, they do account for 50% of re-emissions and must be taken seriously. The objective of this video is to report two rare cases of small bowel obstruction from an internal hernia and a peritoneal defect after minimally invasive sacrocopalpexy. Our first case describes a 55-year-old woman with recurrent stage 3 symptomatic anterior and apical prolapse. She underwent a laparoscopic sacrocopalpexy posterior coporaphy, perineoraphy, and cystoscopy using mesh that was attached to the anterior and posterior vagina with OPD-S suture in an interrupted fashion. The sacral mesh arm was attached to the promontory with hernia tacks and the mesh was completely retroperitonealized using 2-O VLAC suture in a running fashion. She presented to an outside hospital on post-op day 7 with complaints of abdominal pain, nausea, and vomiting. A CT scan revealed a small bowel obstruction, an NG tube was placed, and she was transferred to our institution. The patient was managed conservatively for small bowel obstruction, however, had minimal improvement by hospital day number 5. Review of the axial images of the CT abdomen and pelvis revealed a classic whirl sign as highlighted here. The whirl sign is highly suggestive of intestinal volvulus that occurs when afferent and efferent bowel loops rotate around a fixed point of obstruction. The twisted bowel and mesenteric vessels create swirling strands giving the appearance of a hurricane on a weather map. The sagittal view was reviewed and as you can see here, the sacral tacks are marked with the arrow and the vagina and the mesh are outlined. The arrow demonstrates small bowel that has wrapped behind the sacral arm of the mesh. There was no evidence of bowel ischemia or free fluid. On hospital day number 6, the patient was taken back for a diagnostic laparoscopy. The initial abdominal survey is shown here. As you can see, the small bowel appears fixed in an area near the vaginal apex and small bowel is also noted to be wrapped behind the sacral mesh arm from the right side as seen in the CT scan. Gentle traction was placed on this portion of the proximal small bowel that appeared to be twisted and fixed. The bowel was released after gentle manipulation and was noted to be intact. However, additional small bowel was swept from this right peritoneal space. Upon visualization, you can see an iatric hernia space which had been closed with the initial surgery in which the bowel had been partially trapped. Further inspection revealed a long portion of quill suture which was used to retroperitonealize the sacrocopalpexy mesh which had initially been cut flush with the peritoneum. The small bowel had adhered to this quill suture at multiple points and had most likely created a fulcrum to create a small bowel volvulus. The small bowel was carefully inspected and no injury was noted. Additional inspection revealed the sacrocopalpexy mesh remained completely retroperitonealized and intact but a portion on the right side which had originally been closed off had opened. This created an iatrogenic internal hernia space. In many cases, the bowel may have been able to slide in and out of this space but due to the fixation point on the quill suture, it created an area for small bowel obstruction and volvulus. The elongated portion of the quill suture was cut. The ureter was identified on the right side and the potential space was closed with several delayed absorbable interrupted sutures to prevent future herniation. The small bowel was then completely inspected and appeared healthy and intact without any injury. Several adhesions were lysed between the small bowel as shown here. Post-operatively, the patient's symptoms immediately resolved and she had an uneventful hospital stay and complete recovery. Our second case is an 80-year-old female with stage 3 vaginal valve prolapse who failed conservative treatment with PETS-3 and desired surgical management. The patient underwent a robotic-assisted laparoscopic sacrocopalpexy, bilateral self-injectomy, TBT sling, and cystoscopy. The sacrocopalpexy mesh was attached to the anterior and posterior vagina with PDO quill barbed suture and sutured to the promontory with two Gore-Tex sutures. Mesh was completely retroperitonealized with 2-O polysorb suture. One month post-operatively, the patient presented to an outside hospital with nausea, vomiting, and abdominal pain. CT scan revealed a small bowel obstruction, an NG tube was placed, and she was transferred for surgical management. The sagittal view of her CT was reviewed. The vagina and sacral mesh arm of the sacrocopalpexy are outlined as shown here. Small bowel is noted and circled here in orange. The arrow points to an area of narrowing in the small bowel. This area coincides with the sacral arm of the mesh. Examination of the axial CT shows the vagina and rectum as highlighted here with small bowel protruding in between as pointed out by the arrow. The patient was taken to the OR for diagnostic laparoscopy and initial survey of the abdomen is shown here. The bowel is noted to be distended with filmy adhesions to the anterior abdominal wall. A large amount of fibrin deposition and fluid exudate is seen, suggestive of an inflammatory process. The bowel is retracted and examination of the pelvis is shown here. The small bowel is noted to be traveling on the right side in an internal hernia space similar to the first case, only in this case the bowel is incarcerated underneath the sacral arm of the Y mesh. The distal portion of the bowel is distended and ischemic. Of note, the mesh appears completely retroperitonealized. Gentle traction was placed on the proximal portion of the small bowel in an attempt to release the bowel from the internal hernia. The small bowel was firmly incarcerated underneath the sacrocopalpexy mesh and decision was made to perform a laparotomy, revision of sacrocopalpexy mesh, and small bowel resection with primary reanastomosis. As shown here, the loop of small bowel had clearly become incarcerated when it slipped into the priorly closed right internal peritoneal hernia and underneath the mesh. Post-operatively, the patient had an uneventful hospital stay. In conclusion, this video demonstrates two unusual cases of small bowel obstruction after sacrocopalpexy caused by an internal hernia and a peritoneal defect and entrapment of the small bowel under the sacral Y mesh arm. Of interest, these cases were performed with different minimally invasive surgery, one laparoscopic and one robotic. They were also performed with two different surgeons and two different closure techniques on the peritoneum, absorbable suture versus barbed suture. GI complications are rare with minimally invasive sacrocopalpexy at 1% but are a frequent cause of re-admission. As the number of minimally invasive sacrocopalpexy performed increases, future consideration into the technique for peritoneal burial of the mesh and barbed suture use may be necessary. Thank you for the opportunity to present this surgical video.

small bowel obstruction

laparoscopic sacrocopalpexy procedure

internal hernia

peritoneal defect

mesh entrapment