13: The art of peritoneal closure during sacrocolpopexy

Abstract

To demonstrate an efficient surgical technique for peritoneal closure at the time of laparoscopic sacrocolpopexy. Laparoscopic sacrocolpopexy is a common surgical treatment for pelvic organ prolapse. Closure of the peritoneum over the mesh has historically been recommended by both expert surgeons and mesh manufacturers to decrease the risk of bowel obstruction, adhesion formation, and mesh erosion. Case reports of these complications have been published in the urogynecology and general surgery literature. However, controversy remains as the benefits of re-peritonealization have been difficult to demonstrate, even in studies of up to 400 patients. In addition, many surgeons find this step time-consuming and difficult to perform as the peritoneum is delicate and tears can result in gaps over the mesh or bowel obstruction. In light of the seriousness of bowel obstruction or mesh erosion and the litigious environment in which most gynecologists practice, many surgeons continue to perform peritoneal closure in the absence of further safety data. We present a video demonstrating one surgeon’s technique for efficient peritoneal closure at the time of laparoscopic sacrocolpopexy. Key steps include retraction of the sigmoid epiploica using a stitch pulled through the anterior abdominal wall, creation of a retroperitoneal tunnel from the sacral peritoneal window to the rectovaginal dissection, and use of a monofilament suture for the remaining re-peritonealization. With the appropriate techniques, peritoneal closures over mesh at the time of laparoscopic sacrocolpopexy can be performed with relative ease and efficiency.