28: Vaginal attachment of mesh for sacrocolpopexy at the time of hysterectomy

Abstract

This video aims to show an approach to sacrocolpopexy with vaginal hysterectomy and vaginal attachment of the polypropylene mesh used in the suspension. We present a patient with stage 2 anterior compartment and uterine prolapse. The vaginal hysterectomy is performed first by the resident physician. The cervix is grasped with two Jacobs tenaculi, infiltrated at the incision line with 0.25% bupivacaine, and incised through full thickness epithelium with a curved Mayo scissor. The posterior cul-de-sac is then entered sharply. Lateral pedicles are taken sequentially including sharp anterior entry until the hysterectomy is completed. The rectovaginal dissection is continued to the perineal body and the vesicovaginal dissection is carried out to the ureterovesical junction. Attention is turned to attachment of the mesh. The anterior mesh arm is sutured to the vaginal cuff in the previously dissected space. We include a one centimeter apical "free triangle" which is not be directly sutured to the vaginal cuff, but provides a buffer to reduce the risk of mesh erosion. The Y-stem of the mesh is placed into the abdominal cavity and the posterior arm of the mesh attached within the rectovaginal space. The vaginal cuff is then closed in two layers; the first layer is subcutaneous after which no mesh is visible or palpable at the cuff and the second layer brings together the skin edges with vertical mattress sutures. The sacrocolpopexy is then performed with robotic assistance. Estimated blood loss in this case was 15 milliliters and the patient went home on the day of surgery. At one year postoperatively, the patient was doing well with no recurrent prolapse or surgical complications. The combination of vaginal hysterectomy with sacrocolpopexy ensures our learners gain this important surgical experience while the vaginal placement of the mesh allows for a secure, tension-free attachment.