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Laparoscopic sacrocolpopexy Demonstration of a nerve-sparing technique Dimitri Sarlos, MD; Thomas Aigmueller, MD; Heimo Magg, MD; Gabriel Schaer, MD

Problem: de novo pelvic organ dysfunction Laparoscopic sacrocolpopexy for apical vaginal prolapse has demonstrated excellent anatomic and functional outcomes.1-3 However, de novo pelvic organ dysfunction has been reported after laparoscopic sacrocolpopexy1-5 and may be due to compromise of fibers of the superior hypogastric plexus.6,7 The superior hypogastric plexus is located at the level of the aortic bifurcation and contains mainly sympathetic fibers from the sympathetic trunk. The superior plexus then branches out to form the right and left inferior hypogastric plexuses, which pick up parasympathetic fibers from the splanchnic and inferior mesenteric nerves.8,9 At laparoscopic sacrocolpopexy particularly, dissection of the presacral space can compromise fibers of the superior hypogastric plexus and contribute to postoperative problems such as incomplete voiding, defecatory dysfunction, pain, and sensory problems.5,6 Our solution The Video shows the identification and preservation of the superior hypogastric plexus during the presacral dissection From the Department of Obstetrics and Gynecology, Kantonsspital Aarau, Aarau, Switzerland (Drs Sarlos, Magg, and Schaer); and the Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria (Dr Aigmueller).

Laparoscopic sacrocolpopexy is a well-established technique to treat apical vaginal prolapse. De novo micturition disorders, pelvic pain, and defecation disorders have been reported and may be due to intraoperative compromise of the superior hypogastric plexus. The video demonstrates our technique for nerve-sparing laparoscopic sacrocolpopexy. The patient is a 62-year-old woman with symptomatic stage III posthysterectomy vaginal vault prolapse. Key steps of the procedure are opening the peritoneum at the level of the promontory, identification of the fibers of the superior hypogastric plexus, deep anterior and posterior dissection with attachment of the mesh to the vagina, displacement of the nerve fibers to the left side during suturing of the mesh to the longitudinal ligament, and complete peritonealization. This technique of the identification and protection of relevant nerve structures appears to be reproducible and can be considered by surgeons who perform laparoscopic sacrocolpopexy. Key words: hypogastric nerve, laparoscopic sacrocolpopexy, nerve sparing, prolapse surgery Cite this article as: Sarlos D, Aigmueller T, Magg H, et al. Laparoscopic sacrocolpopexy: demonstration of a nerve-sparing technique. Am J Obstet Gynecol 2015;212:.

at laparoscopic sacrocolpopexy. The key step is visualization and gentle displacement and preservation of fibers of the superior hypogastric plexus at the level of the promontory and right pelvic sidewall. The Video also shows the procedure in a 62-year-old woman with complete posthysterectomy vaginal vault prolapse (cystocele III and rectocele II according to the International Continence

Society/Interational Urogynecology Association-classification). The dissection begins at the vaginal apex, which is demonstrated with a vaginal retractor. The peritoneum is incised, and the bladder is dissected off the anterior vaginal wall. A rectal probe is inserted for better access to the rectovaginal space. The rectovaginal space is dissected to detach the rectum from the posterior vaginal

FIGURE 1

Exposure of the fibers of the superior hypogastric plexus

Received Oct. 1, 2014; revised Nov. 22, 2014; accepted Dec. 2, 2014. The authors report no conflict of interest. Corresponding author: Dimitri Sarlos, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.12.005

Click Supplementary Content under the article title in the online Table of Contents

After the retroperitoneum is opened at the level of the sacral promontory, the fibers of the superior hypogastric plexus are exposed and gently displaced to the left side. Sarlos. Nerve-sparing laparoscopic sacrocolpopexy. Am J Obstet Gynecol 2015.

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Surgeon’s Corner

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FIGURE 2

Suture of the mesh to the longitudinal ligament, I

With the fibers of the superior hypogastric plexus displaced to the left, a good portion of the longitudinal ligament is taken with the needle. Sarlos. Nerve-sparing laparoscopic sacrocolpopexy. Am J Obstet Gynecol 2015.

FIGURE 3

Suturing of the mesh to the longitudinal ligament, II

Final view after of the mesh has been sutured to the longitudinal ligament. The mesh does not impair the nerve fibers. Sarlos. Nerve-sparing laparoscopic sacrocolpopexy. Am J Obstet Gynecol 2015.

FIGURE 4

Complete peritonealization of the mesh

The mesh is completely retroperitonelized with a running suture. Sarlos. Nerve-sparing laparoscopic sacrocolpopexy. Am J Obstet Gynecol 2015.

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wall down to the level of the ventrolateral part of the levator ani muscle. To avoid rectal injury, care is taken not to detach the perirectal fatty tissue from the rectum. The presacral peritoneum is opened on the right side of the midline, and the fibers of the hypogastric plexus are identified under the peritoneum. The nerve fibers cross to the right pelvic wall. They are pushed dorsally away from the site of the later incision of the peritoneum. The segment of the longitudinal ligament is then exposed for later mesh fixation, and the nerves are displaced gently to the left side to avoid impairment (Figure 1). For better exposure of the surgical field, the sigmoid is suspended to the left lateral pelvic wall with a transabdominal suture. The peritoneum is now incised superficially and parallel to the sigmoid to create the retroperitoneal space for the mesh. The superficial incision respects and protects the superior fibers of the hypogastric plexus. An anterior and a posterior piece of macroporous polypropylene mesh (Parietene; Covidien, Dublin, Ireland) are fashioned to the required shape. The posterior mesh is introduced first and attached distally to the levator muscles on either side of the rectum. More proximally, the posterior mesh is sutured to the vaginal apex with nonabsorbable 2-0 sutures (Ethibond Excel; Ethicon Inc, Somerville, NJ). Next, the anterior mesh is introduced and attached to the anterior vagina right at the level of the internal urethral meatus. Apically the anterior mesh is attached with 2 tension-free stitches through the vagina. Now the 2 mesh pieces are attached to the sacrum with 2 stitches through the anterior longitudinal ligament of the promontory (L5). During this step, the nerve fibres are gently displaced to the left, thus avoiding injury (Figures 2 and 3). The entire mesh is then covered by closure of the peritoneum in the midline (Figure 4). Even in absence of prospective data, this technique of the identification and protection of relevant nerve structures appears to be reproducible and can be

Surgeon’s Corner

ajog.org considered by surgeons who perform laparoscopic sacrocolpopexy. REFERENCES 1. Sarlos D, Brandner S, Kots L, Gygax N, Schaer G. Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results, quality of life and perioperative outcome-a prospective study with 101 cases. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1415-22. 2. Sarlos D, Kots L, Ryu G, Schaer G. Long term follow-up of laparoscopic sacrocolpopexy. Int Urogynecol J 2014;25:1207-12.

3. Maher CF, Feiner B, DeCuyper EM, Nichlos CJ, Hickey KV, O’Rourke P. Laparoscopic sacral colpopexy versus total vaginal mesh for vaginal vault prolapse: a randomized trial. Am J Obstet Gynecol 2011;204:360.e1-7. 4. Forsgren C, Zetterstrom J, Zhang A, Iliadou A, Lopez A, Altman D. Anal incontinence and bowel dysfunction after sacrocolpopexy for vaginal vault prolapse. Int Urogynecol J 2010;21:1079-84. 5. Bradley CS, Nygaard IE, Brown MB. Pelvic Floor Disorders Network: bowel symptoms in women 1 year after sacrocolpopexy. Am J Obstet Gynecol 2007;197: 642.e1-8.

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6. Shiozawa T, Huebner M, Hirt B, Wallwiener D, Reisenauer C. Nerve-preserving sacrocolpopexy: anatomical study and surgical approach. Eur J Obstet Gynecol Reprod Biology 2010;152:103-7. 7. Cosma S, Menato G, Ceccaroni M, et al. Laparoscopic sacropexy and obstructed defecation syndrome: an anatomoclinical study. J Int Urogynecol 2013;24:1623-30. 8. Baader B, Hermann M. Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat 2003;16:119-30. 9. Cardozo L, Staskin D. Textbook of female urology and urogynecology, 2nd ed. London: Isis Medical Media; 2006.

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Laparoscopic sacrocolpopexy: demonstration of a nerve-sparing technique.

Laparoscopic sacrocolpopexy is a well-established technique to treat apical vaginal prolapse. De novo micturition disorders, pelvic pain, and defecati...
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