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Abdominal techniques for surgical management of vaginal vault prolapse

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Indications, techniques, and evidence-based rationale


 

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A range of clinical conditions can suggest an abdominal approach for vaginal vault prolapse procedures.

These include, but are not limited to:

  • prior unsuccessful vaginal attempts
  • obligate need for adnexal access
  • markedly foreshortened vagina
  • pelvic bony architectural limitations
  • high risk for surgical failure (eg, athleticism, obesity, chronic obstructive pulmonary disease, congenital connective tissue disorder)
  • desire for uterine preservation

In Part 1 (November 2005) of this 2-part article, we reviewed the most widely used and the newest vaginal techniques. Part 2 focuses on the abdominal approach, and compares vaginal and abdominal approaches.

High uterosacral ligament suspension

Surgical technique for this procedure for mild to moderate vaginal vault prolapse (stage I or II), using a vaginal approach, was described in Part 1, in the November issue of OBG Management. Abdominal repair involves the same concepts; like the vaginal approach, it is applicable only to the patient with mild to moderate vault prolapse. It will be less successful if it is performed to address complete vault prolapse.

Technique

Identify and tag the remnants of the uterosacral ligaments at the level of the ischial spines. Once the ureters are identified and isolated, address the enterocele by obliterating the cul-de-sac via Halban’s culdoplasty or abdominal McCall’s culdoplasty.

Open the peritoneum over the vaginal apex and trim it back to the level of the endopelvic fascia of the vaginal wall. After excising the redundant peritoneum of the vaginal apex, identify and reapproximate the pubocervical fascia of the anterior vaginal wall and the rectovaginal fascia of the posterior vaginal wall using interrupted or running nonabsorbable suture.

Then use nonabsorbable sutures to suspend each corner of the prolapsed vagina from its respective ipsilateral uterosacral ligament.

Abdominal sacral colpopexy

Abdominal sacral colpopexy was first popularized by Addison and Timmons in the 1980s, and is the abdominal standard of apical prolapse repair due to its long-term durability.

Abdominal sacral colpopexy can be performed with or without uterine extirpation. When a hysterectomy is performed concomitantly, some surgeons prefer a supracervical approach, provided there is no history of cervical dysplasia, because, theoretically, the cervical stump serves as a firm and substantial point of fixation for the synthetic mesh that will be used to perform the repair. This in turn may diminish the likelihood of postoperative mesh erosion.

Technique

Reflect the sigmoid colon as far as possible into the left lateral pelvis to expose the sacral promontory. If it has not already been done, free all adhesions between the colon and pelvic peritoneum to fully mobilize the colon and permit its maximal retraction out of the pelvic field prior to making the peritoneal incision.

Also make it a point to identify all structures at risk during this portion of the procedure—namely, the common iliac vessels, ureters, and middle sacral artery and vein. The left common iliac vein is medial to the left common iliac artery and is particularly susceptible to injury during this phase of the procedure.

Make a longitudinal incision in the peritoneum overlying the sacral promontory and extend it approximately 6 cm from the promontory dorsally into the cul-de-sac, opening the retrorectal space (FIGURE 1, TOP). Using a fine tonsil forceps and cautery, very gently dissect the retroareolar filmy tissue overlying the anterior longitudinal ligament away from S1 in thin layers until the white periosteum of the anterior longitudinal ligament overlying S1 is clearly exposed. It now becomes very easy to visualize the course of the middle sacral artery and vein. With these vessels under direct visualization, place 2 permanent #0 sutures through the periosteum of S1.

Do not attempt to place these sutures deeper in the presacral space than the S1 vertebral body, or life-threatening and uncontrollable bleeding may result.

If there is no uterus, insert a probe such as an end-to-end anastomotic sizer or handheld Harrington retractor into the vagina and extend it, elongating and elevating the vaginal cylinder. It now becomes much easier to identify the interface between the bladder and vagina prior to making the peritoneal incision.

If the interface remains indistinct, instill 150 cc of saline into the bladder to delineate its boundaries. Then elevate and incise the vesicouterine peritoneum overlying the junction between the bladder and vaginal apex; this provides access to the vesicocervical space. Dissect the bladder off the anterior vaginal wall in a caudal direction until the pubocervical fascia can be identified. Do not dissect away the peritoneum over the posterior vaginal wall, but leave it intact.

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