Laparoscopic Hysteroperineopexy for Pelvic Dysfunction after Proctocolectomy

Abstract

<h3>Study Objective</h3> To present a case of complex pelvic pain in a patient with a longstanding history of surgical ulcerative colitis and demonstrate an approach to laparoscopic hysteroperineopexy after proctocolectomy. <h3>Design</h3> Case review, followed by demonstration of laparoscopic surgery. <h3>Setting</h3> The patient was placed in a dorsal lithotomy position for laparoscopy in a tertiary care centre. <h3>Patients or Participants</h3> The patient included in this video was encountered in our clinical practice. This 30-year-old G2P2 woman presented with persistent pelvic pressure, pain, and pooling of blood and discharge in the posterior vagina. Her medical and surgical history is complex, including a proctocolectomy for ulcerative colitis. <h3>Interventions</h3> Laparoscopic adhesiolysis, coagulation of pelvic varicocities, and hysteroperineopexy for pelvic dysfunction. <h3>Measurements and Main Results</h3> Based on her pre-operative assessment, this patient's symptoms of pelvic pressure, pain, and pooling of secretions were respectively felt to be caused by adhesions of the small bowel within the empty posterior cul-de-sac, pelvic varicosities, and tethering of the posterior vagina towards the sacrum. In this video, we demonstrate an individualized surgical approach to pelvic dysfunction following proctocolectomy. In step one, her anatomy is restored through adhesiolysis and development of the rectovaginal space. In step two, the varicocities are addressed by opening of the presacral space and ligation of tributaries to the mid-sacral vein. In step three, a hysteroperineopexy is performed for pelvic organ suspension. Post-operatively, this patient's symptoms of pressure and pooling of secretions remain resolved. However, her pain returned three months later. Ligation of varicosities at time of surgery was incomplete due to bleeding, and given her maintained structural restoration, we hypothesize that they may have recurred. Further management through embolization is pending. <h3>Conclusion</h3> Pelvic distortion can be a cause of chronic discomfort, and each patient requires an individualized approach. Hysteroperineopexy, as demonstrated here, may offer significant clinical benefit for some patients.