1. Laparoscopic sacropexy:
an approach to pelvic
prolapse
Jean Pierre Giolitto, M.D.
Polyclinique les Bleuets REIMS - France
SWISS-ENDOS December 2004

2. Introduction
19921996 strict reproduction of the technique by
laparotomy.
19962000 innovative aspects
new anatomic spaces
endoscopic vision
pneumo dissection
20002004 simplification of the technique
reproducibility with acceptable
operating time
excellent results with anatomical
correction and good functional results

3. Preoperative evaluation
Evaluation of the prolapse
degree of prolapse: uterus
bladder
rectum
enterocele
cystocele
central: break of vesico vaginal fascia, vaginal
rugae absent
lateral: vaginal rugae present
higher rectocele (fascia detachment)
lower rectocele (deficient levator ani muscle)

4. Preoperative evaluation
Evaluation of the (in)continence
clinical examination
urodynamic investigation
 prolapse plus pure SUI
 prolapse and hidden SUI
 prolapse without urinary problem
Evaluation of the rectal dysfunction
constipation
fecal or gas incontinence
Evaluation of the enterocele
MRI

5. Preoperative evaluation
Evaluation of the feasibility of laparoscopy
 general anesthesia with pneumo peritoneum
 Trendelenburg position
 older and obese patients
 the vaginal route will not be forgotten

6. Preoperative preparation
Bowel preparation
 empty the bowel and enlarge operating space
 low residual diet 4-5 days prior to surgery
 local enema one day before
Vaginal oestrogens
3 or 4 weeks before
Vaginal and parietal disinfection

7. Preoperative assessment
 Clinical reexamination under general anesthesia
search for new information which might modify the
strategy
 Morphology of the abdominal wall
position of trocars
 pubis – umbilicus distance
 first trocar Ø 10mm: umbilical or supra umbilical
 one 5 or 10mm trocar suprapubic on midline; at
least 6cm between 1st and 2nd
 two 5mm lateral trocars at level of anterior
superior iliac spines

8. Preoperative assessment
Exposition of the operating field
 fixation of the uterus to the anterior abdominal
wall
 fixation of the bowel: sigmoid colon to the left
abdominal wall
Use a 5 or 6cm straight needle with a nylon suture

9. Operating strategy
 Dissection
 promontory: peritoneum to the Douglas
 rectovaginal space
( hysterectomy)
 anterior bladder dissection
 Reconstruction
 first posterior mesh with culdoplasty with
immediate peritonization
 second anterior mesh
 fixation to the promontory
 complete reperitonization

10. Operating strategy
Dissection of the promontory
 Trendelenburg position
 level L5-S1  anterior vertebral ligament
 good care should be taken regarding to
 left iliac vein
 right ureter
 median sacral artery and vein
 lower bifurcation of aorta and obese patients
Incision of the right lateral peritoneum :
 vertical dissection to Douglas pouch
 particular attention should be given to the right ureter

11. Operating strategy
Dissection of the rectovaginal space
 opening of the peritoneum of the Douglas pouch
between the two uterosacral ligaments
 dissection downwards to the posterior vaginal
wall
 identify the rectum and the laterally levator ani
muscles
 use vaginal retractor

12. Operating strategy
Fixation of the posterior mesh
 both lateral sides  levator ani muscles – 2 or 4
non absorbable sutures
 medially and laterally fixation of the mesh to the
vaginal wall without transfixion
 Culdoplasty – Douglas pouch closing without
douglassectomy
 Utero sacral ligaments suture and mesh
reperitonization
 Restore normal anatomy rectum/vagina

13. Operating strategy
Fixation of the second mesh anteriorly
 bladder dissection just above the balloon of the
bladder catheter
 fixation of the mesh with 3 or 5 non absorbable
sutures, non transfixing
 no staples on vagina wall
 passage on the right side through broad ligament
(or bilateral passage)

14. Operating strategy
Sacral colpopexy
 1 or 2 non absorbable suture (staples)
 proper tension with help of vaginal retractor
++ posterior mesh = no tension
++ anterior mesh = tension to correct cystocele
 strong extracorporeal knot
 upper reperitonization
if uterus is left in place: avoid a peritoneum
window between right broad ligament and
posterior peritoneum

15. Operating strategy
Post operative care
Foley catheter 1 or 2 days
Antibio prophylaxis
Prevention of phlebitis
Hospital stay 2 or 3 days
No heavy loads for 6 weeks
No sexual intercourse for 4 weeks

16. Results
Few short term or long term studies
Follow-up
Authors Year N 1 year 2 years
Nezhat 1994 15 100%
Vancaillie 1995 42 90%
Ross 1996 89 95%
Gaston 1999 214 90%
Mandron 2003 263 98%
Bruyere 2002 76 96%

17. Results
Kouri, Cosson: Comparaison de la voie
chirurgicale et coelioscopique, à propos de 218
cas
Group I (SCALI) 100 cases 1990-1995
Group II (laparoscopy) 118 cases 1997-2000
CYSTOCELE 2 or 3
Repaired RECTOCELE:
Group I: 14 posterior perineum
Group II: 2nd laparoscopic sling – 7 cases

18. Results
Kouri, Cosson: Comparaison de la voie
chirurgicale et coelioscopique, à propos de 218
cas
Results at 12 months GROUP I GROUP II
Anatomic result 98 94
Per-op complications 2% 8%
Post-op complications 8% 7%
Hospital stay 8D 5D
Re-intervention rate 2 cases 4 cases

19. Results
Operative time
2 meshes
Year N mn
Cosson 2002 83 292  180
270  100
Bruyere 2001 73
(164)
75
Mandron 2003 100
(45  115)
80
Giolitto 2004 170
(60  110)

20. Results
Cystocele results
Year N 1 year results
Ross 1997 19 100%
Wattiez 1997 92%
Gaston 1999 214 94%
Mandron 2003 263 98%
Giolitto 2004 170 97%
 cystocele degree 4  2
 wait and see
 1 case: second lower mesh
 proper tension with vaginal retractor

21. Results
Rectocele results
 few series with posterior rectal mesh
 open surgery (1 mesh) 33% recurrent rectocele
Year N Results
Lyons 1997 20 80%
Ross 1997 19 84%
Gaston 1999 63 87%
Giolitto 2004 170 95%
 lower rectocele
 posterior mesh  higher rectocele

22. Results
Operative complications
Open conversion
Cosson 6/83 Technical difficulties
Nezhat 1/15 Sacral artery injury
Giolitto 2/170 Technical difficulties
previous abdominal surgery
obesity

23. Results
Bladder injuries
 about 1%
 Giolitto: 4 cases/170
- suture vicryl-monocryl 3-0
- bladder catheter 2-3 days
- antibioprophylaxis 5 days
- negative preoperative urine culture
- no contraindication to fix the mesh

24. Results
Post-operative complications
 brochial plexus injury
Bruyere 1 case
 post operative bowel obstruction
Gaston 4 cases
1 hernia trocar
3 inadequate reperitonizations (1 ileal resection)
Giolitto 3 cases
3 inadequate reperitonizations (1 ileal resection)

25. Results
Post-operative complications
Spondylitis
Giolitto 0
Gaston 2 cases
1 case with post operative haematoma
1 case with hysterectomy
Butreau 1 case
Diagnostic
- at 2 to 6 months
- removal of the meshes

26. Results
Long term complications
 Second vagina mesh displacement
Gaston 9 cases/429
posterior mesh but fixation with continuous sutures
(vagina ischemia)
prevention fixation with 3 or 5 separate nonabsorbable
sutures on posterior vagina
 Post operative constipation
1 month 6 months
Previous posterior fixation 90% 13%
New posterior fixation with
15% 10%
broad mesh
Mandron 70 cases - 2004

27. Conclusion
Laparoscopy
 advantage of the treatment by laparotomy
 low morbidity such as the vaginal route
 reproducibility of the technique
 time: around 90 minutes
 further studies required