04: A novel method of vaginal extraperitoneal colpopexy by sacrospinous ligament fixation using biologic grafts in the post mesh era

Abstract

Biologic Grafts are alternative to Mesh in vaginal extraperitoneal colpopexy procedures given the FDA removal of Mesh products. Our video describes a novel method in which a biological graft is used for vaginal prolapse procedures. Step 1: Distension of Vesicovaginal space with local anesthetic, dissection of vaginal wall through all histological levels of the vagina to reach vesicovaginal space, extending dissection to urethral vaginal junction anteriorly and to the cervix posteriorly. Step 2: Continue dissection of bladder away from vagina laterally with tenotomy or Metzenbaum scissors, enter the paravaginal space behind the vaginal wall, through the facial endopelvina, using blunt dissection to access sacrospinous ligament and coccygeous muscle complex through endopelvina connective tissue bilaterally. Step 3: Place vaginal fixation sutures to posterior of vagina at the level of the UVJ. Keep needle and suture in place and clamp with hemostat without tying. Step 4: Using Anchosure device, deploy anchor within the lower 1/3 and medial 1/3 of the sacrospinous ligament with Prolene suture. Confirm proper placement with palpation. Step 5: Cut out biologic graft to specific dimensions. Step 6: Using Mayo needle, attach one end of sacrospinous ligament fixation sutures through the biologic graft. Attach other end of sacrospinous ligament fixation suture through biologic graft while fixating suture through cervical stroma. Step 7: Push arms of Biologic Graft down to the level of the sacrospinous ligaments along with the Prolene sutures, Tie each side of suspension sutures carefully to avoid unwanted lateral movements of the suspension. Finally close remainder of vaginal incision. The procedure is minimally invasive, requires no mesh implants, and provides an alternative to vaginal extraperitoneal prolapse procedures previously utilizing mesh.